Value-based Healthcare Models Research Articles

Enhancing Value and Well-Being: The Basket of Motivators Framework for Aligning Neurology Clinical Practices With Performance Outcomes.

Physician burnout, which is prevalent in neurology, has accelerated in recent years. While multifactorial, a major contributing factor to burnout is a payment model that rewards volume over quality, leaving physicians overburdened and unfulfilled. The aim of this review was to investigate ways of reducing burnout while improving quality-based outcomes in a value-based health care model. Burnout affects researchers, educators, clinicians, and administrators in all fields and tracks, but neurologists experience some of the worst burnout rates among specialties. Transitioning to a value-based health care model, which rewards quality and outcomes over volume, may contribute to reversing the burnout trend. However, this requires that physicians feel valued in the workplace in ways corresponding to their preferences. We propose to stratify neurologists using the "basket of motivators" framework, which operates multiple individual-based and team-based motivators including balance among work responsibilities, work-life balance, institutional pride, self-actualization at work, work environment, and finances. By tailoring individual-based and team-based financial and nonfinancial incentives, neurologists are empowered to work at the top of their license to provide high-impact clinical care while combating the most prominent causes of burnout. To address the neurologist burnout epidemic, a transition to value-based health care is needed that rewards quality-based performance outcomes through both individual-based and team-based approaches that apply financial and nonfinancial incentives. Understanding the underlying motivations behind neurologists' drives to work can inform tailored incentives that allow neurologists to provide value to their patients and feel valued by their organizations.

Value-Based Healthcare Delivery: A Scoping Review.

Healthcare systems are transforming from the traditional volume-based model of healthcare to a value-based model of healthcare. Value generation in healthcare is about emphasising the health outcomes achieved by patients and organisations while maintaining an optimal relationship with costs. This scoping review aimed to identify the key elements and outcomes of implementing value-based healthcare (VBHC). The review process included studies published from 2013 to 2023 in four different databases (SpringerLink, PubMed, ProQuest and Scopus). Of the 2801 articles retrieved from the searches, 12 met the study's inclusion criteria. A total of 11 studies referred to value as the relationship between the outcomes achieved by patients and the costs of achieving those outcomes. Most of the studies highlighted the presence of leadership, the organisation of care into integrated care units, the identification and standardisation of outcome measures that generate value for the patient, and the inclusion of the patient perspective as the most prominent key elements for optimal VBHC implementation. Furthermore, some benefits were identified from VBHC implementation, which could shed light for future implementation actions. Therefore, the VBHC model is a promising approach that may contribute to an improvement in the efficiency and sustainability of healthcare.

The Role of Regional Anaesthesia and Acute Pain Services in Value-Based Healthcare.

Value-based healthcare prioritizes patient outcomes and quality relative to costs, shifting focus from service volume to delivered value. This review explores the significant role of regional anaesthesia (RA) and acute pain services (APS) within the evolving value-based healthcare (VBHC) framework. At the heart of VBHC is the goal to enhance patient outcomes while simultaneously optimizing operational efficiency and reducing costs. The review underscores the need for VBHC and illustrates how integrating RA/APS with Enhanced Recovery Protocols can lead to improved outcomes, aligning directly with the goals of the Triple Aim. Several clinical studies show that RA improves patient outcomes, enhances operating room efficiency, and reduces costs. This is complemented by a discussion on the integration of RA and APS into the VBHC model, highlighting emerging value-based payment structures and strategies for their successful implementation. By merging specialized RA/APS protocols with standardized clinical practices, significant improvements in operating room efficiency and associated economic benefits are observed. Across the healthcare spectrum, from providers to payers, this synergy results in enhanced operational efficiency and communication, raising the standard of patient care. Additionally, the potential of RA and APS to address the opioid crisis, through alternative pain management methods, is emphasized. Globally, the shift towards VBHC requires international collaboration, sharing of best practices, and efficient resource allocation, with RA and APS playing a crucial role. In conclusion, as healthcare moves toward a value-driven model, RA and APS become increasingly essential, signaling a future of refined, patient-centered care.

A value-based healthcare model for initiating and switching psoriasis therapies-Results from the prospective multicentre IMPROVE study.

Little is known about the therapeutic benefits of a value-based healthcare model compared to a traditional activity-based incentive model in psoriasis (PsO). This prospective non-interventional study evaluated an outcome-based, patient-centred management model for patients with PsO. In total, 49 patients with a Psoriasis Area and Severity Index (PASI) ≥3 who were starting or switching between treatments were included. Patients were assessed at baseline, 3 and 9 months. The patient benefit index (PBI) was calculated using predefined questionnaires. An expected PBI was calculated and adjusted for risk factors known to complicate treatment, that is overweight and smoking. The model remunerated the department on whether the observed PBI exceeded the expected PBI to incentivize over-performance. In total, 40 patients (80%) completed all three visits; 32.7% were smokers and 73.5% were overweight. Mean PASI at baseline was 11.5 (SD 9.1); PASI improved significantly from baseline through 3 months: mean reduction, 8.0 (SD 9.2), p < 0.001 and was maintained until 9 months: mean further reduction, 0.1 (SD 3.3), p = 0.893. The mean PBI was 2.5 (SD 1.3) and 2.8 (SD 1.1) at 3 and 9 months, respectively. A PBI ≥1 was achieved by 87.8% at 3 and 95.1% at 9 months. Overall, the department was remunerated a mean 2721.1 DKK (SD 4472.8) per patient. In subgroup analysis, the department was remunerated a mean of, respectively, 2428.6 (SD 5089.5), 2636.6 (SD 4471.3) and 3196.5 (SD 4497.1) DKK for patients with none, 1 or 2 risk factors, that is smoking or/and overweight. The model evaluated herein is the first value-based model to calculate remuneration from patient reported outcomes and showed to successfully predict the expected PBI and remunerate treatment based on whether the expected treatment goal was met or exceeded. This can be utilized in the patient-centred management of PsO.

Transformation of management of dental organizations in the conditions of transition to a value-based healthcare model

Aim. To develop recommendations for management consulting on practical implementation of the model of value-oriented approach in medical organizations of dental profile.Objectives. To analyze the experience of implementing the elements of the value-oriented approach in the management of dental organizations in foreign medical practice and dental institutions of the Russian health care system; to review foreign and domestic scientific literature in the context of the research topic; to study and apply the data of analytical reports of specialized international organizations.Methods. The authors used general scientific and special scientific methods. The analysis of domestic and foreign scientific publications in the context of the research topic was presented, and also methods of modeling, applied qualitative content analysis of information were applied.Results. The article investigates the models of implementation of the value-based approach in the organizations of the health care system abroad. The dissemination of the elements of this model in domestic dental institutions was analyzed. The conclusions about the main obstacles in the implementation of the principles of value-oriented approach in Russian dentistry are made. Recommendations on forms and methods of management consulting for effective implementation of the value-oriented health care model in the stomatological sphere of medical activity are formulated.Conclusions. According to the evaluations of pilot projects and indicators of scientific calculations, the transition to the system of value-oriented health care is slow, but it is recognized as an inevitable and necessary vector of health care development. Taking into account the socially useful effect of this model, the need for the Russian system of state guarantees of health care in the introduction of a value-oriented approach is extremely high. Further practical, research activities are necessary to develop tools for implementing the principles of value-oriented approach in the dental sphere.

Implications of immersive technologies in healthcare sector and its built environment.

This research focuses on how built environment experts can contribute to the MXR-enabled digital innovation as part of the multidisciplinary team effort to ensure post-pandemic resilience in healthcare built environment. The goal of this research is to help healthcare providers, built environment experts, and policy makers respectively: (1) Advocate the benefits of MXR for innovating health and social care; (2) Spark debate across networks of expertise to create health-promoting environment; and (3) Understand the overriding priorities in making effective pathways to the implementation of MXR. To highlight the novelty of this research, the study relies on two qualitative methodologies: exploratory literature review and semi-structured interviews. Based on the evaluation of prior works and cross-national case studies, hypotheses are formulated from three arenas: (1) Cross-sectional Initiatives for Post-pandemic Resilience; (2) Interoperability and Usability of Next-gen Medicines; and (3) Metaverse and New Forms of Value in Future Healthcare Ecosystems. To verify those hypotheses, empirical findings are derived from in-depth interviews with nine key informants. The main findings are summarized under the following three themes: (1) Synergism between Architecture and Technology; (2) Patient Empowerment and Staff Support; and (3) Scalable Health and Wellbeing in Non-hospital and Therapeutic Settings. Firstly, both built environment and healthcare sectors can benefit from the various capabilities of MXR through cross-sectional initiatives, evidence-based practices, and participatory approaches. Secondly, a confluence of knowledge and methods of HCI and HBI can increase the interoperability and usability of MXR for the patient-centered and value-based healthcare models. Thirdly, the MXR-enabled technological regime will largely affect the new forms of value in healthcare premises by fostering more decentralized, preventive, and therapeutic characteristics in the future healthcare ecosystems. Whether it's virtual or physical, our healthcare systems have placed great emphasis on the rigor of evidence-based approach linking health outcome to a clinical environment. Henceforth, built environment experts should seek closer ties with the MXR ecosystems for the co-production of scalable health and wellbeing in non-hospital and therapeutic settings. Ultimately, this is to improve resource efficiency in the healthcare sector while considering the transition of health resources towards in silico status by increasing the implementation of MXR.

Transition to Value-based Healthcare: Development, Implementation, and Results of an Optimal Surgical Care Framework at a National Cancer Institute–designated Comprehensive Cancer Center

BackgroundThe continued rise in healthcare expenditures has not produced commensurate improvements in patient outcomes, leading US healthcare stakeholders to emphasize value-based care. Transition to such a model requires all team members to adopt a new strategic and organizational framework. ObjectiveTo describe and report a strategy for the implementation of a novel patient-centered value-based “optimal surgical care” (OSC) framework, with validation and cost analysis in kidney surgery. Design, setting, and participantsAn observational study of care episodes at a single institution from 2014 to 2019 was conducted. Outcome measurements and statistical analysisMultidisciplinary teams defined OSC by core and procedure-specific metrics using a combination of provider-based (“bottom-up”) and “clinical leadership”-based (“top-down”) strategies. Baseline OSC rates across were established, while identifying proportions of OSC achieved by coefficient of variation (CV) in total direct costs. Multivariable linear regression comparing cost between OSC and non-OSC encounters was performed, adjusting for patient characteristics. Results and limitationsAn analysis of 30 261 perioperative care episodes was performed. Following the implementation of an OSC framework, there was an increase in OSC rates across all procedure buckets using core (25%) and procedure-specific (26%) metrics. Among the tumors tested, kidney cancer surgical episodes held the highest OSC rate improvement (67%) with lowest variability in cost (CV 0.5). OSC was associated with significant total cost savings across all tumor types after adjusting for inflation (p < 0.05). Compared with non-OSC episodes, a significant reduction in the cost ratio of OSC was noted for renal surgery (p < 0.01), with estimated costs savings of $2445.87 per OSC encounter. ConclusionsInstitutional change directing efforts toward optimizing surgical care and emphasizing value rather than focusing solely on expense reduction is associated with improved outcomes, while potentially reducing costs. The strategy for implementation requires serial performance analyses, engaging and educating providers, and continuous ongoing adjustments to achieve durable results. Patient summaryIn this study, we report our strategy and outcomes for transitioning to a value-based healthcare model using a novel “optimal surgical care” framework at a National Cancer Institute–designated comprehensive cancer center. We observed an increase in optimal surgical care episodes across all specialties after 5 yr, with a potential associated reduction in cost expenditure. We conclude that the key to a successful and sustained transition is the implementation strategy, focusing on continual review and provider engagement.

Acceptability of the routine use and collection of a generic patient reported outcome measure from the perspective of healthcare staff: a qualitative study

BackgroundPatient-reported outcome measures (PROMs) provide a measure of self-perceived health status or health-related quality of life. They have been used to support provider-patient decisions, healthcare delivery, and value-based healthcare models. A barrier to routine collection of PROMs is the perception that PROMs lack clinical utility. As such, it is important to establish clinicians’ acceptability of the PROM prior to large-scale implementation. This study explored the acceptability of the routine use and collection of a generic PROM in healthcare services from the perspective of healthcare staff.MethodsIndividual semi-structured interviews were completed from September 2020 to March 2021 with 26 staff from two multi-disciplinary community healthcare services in Melbourne, Australia. Interviews explored their experiences of using the EQ-5D-5L in their routine care. Interviews were recorded and transcribed verbatim. Data were analysed according to a framework approach, using inductive and deductive techniques.ResultsParticipants discussed the acceptability of the EQ-5D-5L with reference to four themes: practicalities of use; holistic nature; influence on client care; and influence on health service. Participants found the EQ-5D-5L quick and easy to administer, and appreciated that it measured multiple domains of health that were relevant to their clients’ care. They believed the EQ-5D-5L helped to identify client problems, and inform service delivery. They also reported features that were less acceptable, including a lack of item specificity to some healthcare disciplines. Participants reported the challenge of managing conflict between their assessment of the client’s health and the client’s perspective of their own health, leading some to question whether the client could provide an accurate reflection of their own health.ConclusionsThe EQ-5D-5L has several features that healthcare staff viewed as acceptable for routine collection and use in healthcare. Training on the validity of the patient reported perspective and broadening the scope of PROMs collection beyond the EQ-5D-5L should be considered to facilitate large-scale implementation.

Применение информационных технологий в оценке качества оказания медицинской помощи

The currently relevant value-based healthcare model (Value-Based Healthcare) is more focused on ensuring long-term effectiveness and patient satisfaction, which is directly related to the implementation of the principles of patient-oriented and patient-centered activities [1]. In accordance with the Proposals (practical recommendations) on the organization of internal quality control and safety of medical activities in a medical organization (hospital) of the Federal State Budgetary Institution “National Institute of Quality” of Roszdravnadzor, compliance with the principles of patient-centered medical care provides for the development and implementation at the level of a medical organization of a patient safety strategy, including compliance with ethical standards and rules in the implementation of medical care activities. This also includes the procedure for organizing feedback with patients [15]. The use of information technologies in patient questionnaires and analysis of results allows for operational monitoring of patient satisfaction indicators and to create a basis for assessing most aspects of hospital activities from the perspective of patients: the quality of medical services and their results, interaction with staff, infrastructure and service components. The purpose of the study is to provide the results of the implementation of the author’s information and analytical system for collecting and processing information about patient satisfaction through an electronic web questionnaire and providing the calculation of satisfaction indicators in a multidisciplinary hospital. M a t e r i a l s a n d m e t h o d s . The basis of the study was a multidisciplinary hospital of the state budgetary healthcare institution “Regional Clinical Hospital No. 2” in Vladivostok. Within the framework of the study, the inpatient patients were surveyed using questionnaires in electronic form prepared by a medical organization, an information and analytical system was developed to conduct a mathematical analysis of the results of the survey according to five criteria for assessing the quality of medical care conditions. The study used a questionnaire including 20 questions, the answers to which express the opinion of patients about the quality of work of doctors and nursing staff, the comfort of the conditions of stay in the emergency department, as well as in the hospital during hospitalization. The questionnaire was developed in 2015, and for many years the survey was conducted using paper and manual calculations. But since 2021, patient questionnaires and analysis of the collected data have been transferred to an electronic format. In this article we present the results obtained with the help of an information system for collecting and analyzing questionnaires, in which adult patients of a round-the-clock hospital participated. R e s u l t s . The use of information technologies in patient questionnaires and analysis of results allows for operational monitoring of patient satisfaction indicators and to create a basis for assessing a number of aspects of hospital activity from the perspective of patients: the quality of medical services and their results, interaction with staff, infrastructure and service components make it possible to evaluate the effectiveness of measures to ensure comfortable conditions for the patient’s stay and can be used in practical healthcare to organize measures to eliminate defects and make decisions on the management of a medical organization. C o n c l u s i o n s . The introduction of additional methods for studying patient satisfaction using electronic forms, taking into account the specifics of the work of a medical organization to the requirements established by the Ministry of Health of the Russian Federation, makes it possible to increase the effectiveness of interaction with patients and can be one of the tools for assessing the social effectiveness of a medical organization (hospital).

Value-based health care: alignment the tools and methods (literature review)

The desire to solve the problem of efficient spending of funds in the public sector has been transformed into an understanding of values. The desire to reduce costs, maintain the proper quality and maximize the availability of medical care led to the emergence and formation of a new concept of effective functioning based on values - VBHC (Value-based Health Care). Purpose. To systematize the criteria, metrics and methods for evaluating effectiveness in the context of the VHBC concept. To obtain the necessary information, a selective literature review was carried out. Electronic bibliographic databases in Russian (“RSCI/eLibrary”) and English (“Pubmed”) were used. Search queries were formed taking into account the MeSH nomenclature. To determine the effectiveness of the provision of medical services and the implementation of government programs (projects) in general, there are a number of methods. First of all, it is an analysis of costs, benefits, effectiveness and benefits. The most applicable performance measure is Quality Adjusted Life Years. QALY is a universal indicator of any health program. This expression of “utility” is by default the ultimate goal (final target unofficial indicator) of any government management decision in health care. Assessing the effectiveness of health care and developing a value-based model of health care through cost-benefit analysis is a time-consuming and important task. The study showed that it is necessary to use multidimensional tools for assessing the effectiveness of medical care. Conclusions. As a result of the review, it was found that there is no unified information system that offers ready-made assessment tools, and metrics have not been developed to evaluate the effectiveness of value-based healthcare VBHC models. It seems possible to create a checklist with universal parameters, implement it into a ready-made information system available on the market today to any medical institution, and analyze the effectiveness of the VBHC model based on the developed checklist.

Incorporating Paid Caregivers Into Medical Education to Enhance Medical Student Exposure to This Essential Workforce

The implications of the COVID-19 pandemic underscored the utility of home-based health care due in part to social distancing requirements, curtailment of elective hospital procedures, and patient apprehension of the health care setting. The pandemic particularly accentuated the integral role of paid caregivers (eg, home health aides, personal care attendants, and other home care workers) in caring for patients with chronic health conditions. Given the paradigm shift toward community- and value-based health care models, paid caregivers are likely to play an even greater role as care team members. Despite the increasingly prominent role paid caregivers are assuming in health care, especially for patients who are chronically ill, in our experience as medical students, we have very little exposure to these care team members, with most interactions occurring in brief, chance encounters. Specifically, we advocate for increased medical student exposure to paid caregivers to facilitate their recognition as valuable care team members. We propose to achieve this through (1) classroom-based module learning with live paid caregivers and (2) plain language communication training to enhance reciprocal engagement.

An evaluation of value-based outcomes for women admitted to a dialectical behaviour therapy integrated practice unit: a follow-up study.

An earlier evaluation (Fox et al., ) highlighted reductions in risk behaviours and restrictive practices for women admitted to low secure dialectical behaviour therapy (DBT) unit. Since then, a value-based healthcare model has been adopted. To explore changes in health, social and psychological functioning, risk, quality of life, and in incidents of violence and restrictive practices, over the initial 12-month period of admission to a specialist DBT service. Data were extracted from electronic clinical records for 41 women with emotionally unstable personality disorder admitted to a specialist integrated practice unit (IPU) providing a comprehensive DBT programme. Secondary analysis was conducted on an anonymous dataset of routinely collected outcome measures at baseline admission, and 6 and 12 months post-admission. ANOVAs and pairwise post hoc comparisons, and non-parametric equivalents, were conducted to examine changes in outcomes. Findings showed statistically significant improvements in mental health scores on the ReQOL (p<.01), global, wellbeing, problems, functioning and risk scores on the COREOM (all p<.01), and severe disturbance, emotional wellbeing, socioeconomic status, risk and need scores on the HoNOS-Secure (all p<.05). Significant reductions in risk behaviours (p<.01) and restrictive practices (p<.01) were also apparent. The most substantiative improvements were largely demonstrated over a 12-month admission period. Admission to the DBT IPU yielded significant improvements on outcomes pertaining to quality of life, psychological distress, and risk. Importantly, these are outcomes that aligned with patients' perceptions of recovery.

Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations?

Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients.

Medicaid long-term care workforce training intervention and value-based payment metrics.

To examine the impact of a scaled implementation of workforce training intervention on value-based payment measures in a large home-based Medicaid managed long-term care plan population in New York. Managed long-term care clients' health assessments from the Uniform Assessment System of New York merged with paid claims, home health aide operational visit data, and workforce training rosters between 2018 and early-2020. A quasi-experimental design was used. Exposure and control groups were constructed using the proportion of service hours delivered by trained aides between clients' baseline and follow-up/outcome assessments. Multivariate logistic generalized linear and additive models were estimated to examine associations between exposure to trained aides and value-based payment measures. The analytic sample consisted of 19,212 pairs of assessments from 13,320 long-term care clients continuously enrolled in the plan between baseline and follow-up/outcome assessments. Matched assessment pairs were 6-10months apart. Over 27% of the study population (n=3656 clients) received services from one or more of 8683 trained aides. Statistically significant associations were observed for four of seven value-based payment measures; however, the presence and magnitudes of positive training effects differed by client service needs. With covariate adjustment, workforce training had the largest estimated positive impacts on rates of flu vaccination among average-need clients (1.60%, standard error [SE]=0.01), not experiencing uncontrolled pain among above-average-need clients (0.69%, SE=0.001), stable/improved pain intensity among heavy-need clients (1.25%, SE=0.01), and stable/improved shortness of breath among light-need clients (0.88%, SE=0.003). Although we found mixed associations between scaled workforce training implementation and value-based payment metrics, we noted workforce training could benefit high-need long-term care recipients. Health indicators more sensitive to the daily support provided by direct care workers should be integrated into value-based health care models.

Lessons learned on the experienced facilitators and barriers of implementing a tailored VBHC model in a Dutch university hospital from a perspective of physicians and nurses

ObjectiveThis study aims to obtain insight into experienced facilitators and barriers of implementing a tailored value-based healthcare (VBHC) model in a Dutch university hospital from a perspective of physicians and...

Value-Based Health Care for Children with Congenital Heart Diseases: A Feasibility Study from a Low–Middle Income Country

Summary Quality health care is lacking in low–middle income countries (LMICs), which results in significant mortality and economic loss. Congenital heart disease (CHD) is a resource-intensive disease, and lack of resources in LMICs makes it challenging for health care providers to deliver quality care to these patients. A value-based health care (VBHC) approach can be useful in addressing these challenges and can help address patients’ needs by adopting innovative resource utilization. In this article, the authors aim to address the feasibility of implementing a VBHC model for patients with CHD in Pakistan through multiple initiatives taken over time at a single tertiary care center. They assess the six components of VBHC proposed by Porter and Lee in their strategic value agenda for each of the initiatives, highlight the challenges and successes of their efforts to implement VBHC at their center, and determine its relevance and sustainability in an LMIC.

Use of social determinants of health codes in home-based primary care.

The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data. The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH). Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes. Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded. Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support. By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.

The unsustainable bubble of disease-modifying antirheumatic drugs in rheumatology

The high prices of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) put pressure on the health-care budgets for patients with rheumatic musculoskeletal diseases. High prices appear to reflect added value. According to the value-based health-care model, value is proportional to patient-reported outcomes and experiences (satisfaction) and inversely proportional to health-care costs. The question addressed in this Viewpoint is whether the many novel DMARDs, all of which are similarly effective and safe but disproportionally expensive in comparison to conventional synthetic DMARDs, fulfil the promise of added value. It is proposed that the added value of the newest biological and targeted synthetic DMARDs is questionable at best, and that their added value is limited to patients who do not respond adequately to standard-of-care treatment. The added value for each novel DMARD decreases with each additional DMARD that obtains market authorisation, and the number of patients with treatment-refractory disease declines as a result of an ever-improving standard of care. Yet, the prices of DMARDs remain high and even tend to increase. Explanations for the perpetually high cost of these drugs despite a dubious added value relate to system characteristics, such as regulatory uncoupling of drug approval, pricing, and reimbursement; profuse and effective marketing of novel drugs; the existence of strategic patenting; and effective lobbying. To constrain DMARD expenses in rheumatology, to put more pressure on manufacturers, and to serve as many patients with rheumatic and musculoskeletal diseases as possible with affordable care, I propose that rheumatologists judge more critically which patients truly need expensive DMARDs and choose more wisely. Four simple behavioural measures are proposed to this end. The high prices of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) put pressure on the health-care budgets for patients with rheumatic musculoskeletal diseases. High prices appear to reflect added value. According to the value-based health-care model, value is proportional to patient-reported outcomes and experiences (satisfaction) and inversely proportional to health-care costs. The question addressed in this Viewpoint is whether the many novel DMARDs, all of which are similarly effective and safe but disproportionally expensive in comparison to conventional synthetic DMARDs, fulfil the promise of added value. It is proposed that the added value of the newest biological and targeted synthetic DMARDs is questionable at best, and that their added value is limited to patients who do not respond adequately to standard-of-care treatment. The added value for each novel DMARD decreases with each additional DMARD that obtains market authorisation, and the number of patients with treatment-refractory disease declines as a result of an ever-improving standard of care. Yet, the prices of DMARDs remain high and even tend to increase. Explanations for the perpetually high cost of these drugs despite a dubious added value relate to system characteristics, such as regulatory uncoupling of drug approval, pricing, and reimbursement; profuse and effective marketing of novel drugs; the existence of strategic patenting; and effective lobbying. To constrain DMARD expenses in rheumatology, to put more pressure on manufacturers, and to serve as many patients with rheumatic and musculoskeletal diseases as possible with affordable care, I propose that rheumatologists judge more critically which patients truly need expensive DMARDs and choose more wisely. Four simple behavioural measures are proposed to this end.

Concept of value-based healthcare

This article contains the aims and main principles of the concept of value-based healthcare (VBHC). The relevance of the implementation of this approach into the Russian healthcare system results from the fact that during the control and payment for medical care, the treatment outcomes are evaluated selectively and at separate stages. The medical care payment system considers only its volumes and not achieving the desired treatment outcome significant to a patient. A review of the world’s best practices of introducing VBHC conception and, also new medical care payment methods such as bundled payment and pay-for-performance (P4P) has been conducted. According to international experience, VBHC increases the quality of medical care and provides the optimization of costs. To implement VBHC model in the Russian Federation, it is necessary to ensure the informatization of the providing medical care, development, and improvement of medical quality control systems (development of the resulting criteria for medical care quality for all diseases), and introduction of the rating system for medical organizations. Provided these processes are ensured, further progressing to P4P is possible. Moreover, it would also be feasible to implement VBHC in other healthcare processes including procurement of drugs and medical devices, their pricing, and reimbursement.

Surgical Management of Obesity in Brazil: Proposal for a Value-Based Healthcare Model and Preliminary Results

ObjectivesTo describe the implementation and 1-year results of a value-based bariatric surgery program in Brazil. MethodsThe study was conducted at a private hospital in São Paulo, Brazil (Hospital Alemão Oswaldo Cruz). A value-based healthcare program was implemented by designing an episode of care for eligible patients and developing a bundled payment model in which a single payment was made for the bariatric surgery covering the preoperative workup and ending 30 days after discharge. Assessment of outcomes included complication rate, hospital length of stay, intensive care admissions, reoperations, readmissions, and visits to the emergency department in the 30-day postoperative period. The results were compared with real-world evidence retrieved from a Brazilian private insurance database containing information on bariatric procedures performed in similar institutions (benchmark group). ResultsEighty-three patients were enrolled in the value-based healthcare program (80.7% women; 18.0% with type 2 diabetes mellitus; 31.0% with high blood pressure). The mean age was 40.9 years, and body mass index was 42.1 kg/m2. The outcomes recorded in the benchmark group versus the value-based healthcare group involved complication rate, 2.6% versus 1.4% (P = 0.69); length of stay, 2.5 versus 2.0 days (P = 0.0001); intensive care admissions, 4.0% versus 1.2% (P = 0.31); emergency care visits, 15.0% versus 6.0% (P = 0.04); and readmissions, 2.3% versus 0 (P = 0.35), with an estimated cost reduction of 7.1%. ConclusionsThese initial results showed favorable surgical and 30-day outcomes, demonstrating the benefits of a value-based approach for the surgical management of obesity and its comorbidities.