Redefining value: a discourse analysis on value-based health care

Abstract

Background Today’s remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. This is evident within academic publications, and mirrored in fragmented and diversified implementation efforts, both within and across countries. Method This article builds on discourse analysis in order to map the ambiguity surrounding VBHC. We conducted a document analysis of publicly accessible, official publications (n = 22) by actors and organizations that monitor and influence the quality of care in the Netherlands. Additionally, between March and July 2019, we conducted a series of semi-structured interviews (n = 23) with national stakeholders. Results Our research revealed four discourses, each with their own perception regarding the main purpose of VBHC. Firstly, we identified a Patient Empowerment discourse in which VBHC is a framework for strengthening the position of patients regarding their medical decisions. Secondly, in the Governance discourse, VBHC is a toolkit to incentivize providers. Thirdly, within the Professionalism discourse, VBHC is a methodology for healthcare delivery. Fourthly, in the Critique discourse, VBHC is rebuked as a dogma of manufacturability. We also show, however, that these diverging lines of reasoning find common ground: they perceive shared decision-making to be a key component of VBHC. Strikingly, this common perception contrasts with the pioneering literature on VBHC. Conclusions The four discourses will profoundly shape the diverse manners in which VBHC moves from an abstract concept to the practical provision and administration of health care. Moreover, our study reveals that VBHC’s conceptual ambiguity largely arises from differing and often deeply rooted presuppositions, which underlie these discourses, and which frame different perceptions on value in health care. The meaning of VBHC – including its perceived implications for action – thus depends greatly on the frame of reference an actor or organization brings to bear as they aim for more value for patients. Recognizing this is a vital concern when studying, implementing and evaluating VBHC.

From centralized DRG costing to decentralized TDABC-assessing the feasibility of hospital cost accounting for decision-making in Denmark

“…In recent years, we have witnessed an increasing interest in a value-based agenda [ 25 , 26 , 35 – 37 , 63 , 64 ] based on the ideas of Porter, Kaplan, and others [ 21 , 22 , 29 ] with a developing focus on the costing techniques of TDABC [ 4 , 9 , 16 , 27 , 28 ]. This trend is also seen in the Danish healthcare system [ 25 , 47 , 55 ], and as stated by Triantafillou (2020), referring to the national patient registry, “Only very few countries in the world have a population whose dealing with the public sector is so intensely and systematically monitored and registered as in Denmark” ( [ 25 ] , p. 6), which has been supported by other studies [ 54 ].…”

“…Steinmann et al [ 26 ] highlight that the concept of VBHC is ambiguous, particularly the idea of patient value, which is perceived as the patient–doctor relationship experience in the Netherlands rather than a strategic goal for healthcare as the theory proposes, which has connotations with Groenewoud and colleagues’ [ 65 ] concerns about the ethical drawbacks of VBHC where they highlight a neglecting of patients’ intrinsic values. Triantafillou [ 57 ] has similar concerns in a Danish setting as is further highlighted by other studies.…”

“…Theoretically, cost accounting has long been part of the foundation for diagnosis-related group (DRG) rates, which are applied in most OECD nations for benchmarking, pricing, and/or hospital resource allocation [10,12,20]. Moreover, cost accounting is a vital part of the newly defined value-based healthcare (VBHC) agenda [21,22], which seeks to investigate the patient's total use of resources across healthcare departments and organizations [9,[23][24][25][26] through the particular application of TDABC [6,16,27,28]. Additionally, cost accounting is highlighted to be of vital socio-political importance for "solving the cost crisis in healthcare" [29] and achieving cost-effective delivery of healthcare [5,14].…”

Decision-making in complex health care situations: Shared understanding, experimenting, reflecting and learning

“…7 This is difficult to reconcile with the Ministry’s commitment to outcome-based care and Porter’s model 8 of value-based health care. 9 Both involve pitfalls for people with complex problems. If information is limited to a specific subset of quantitative data, there is a risk that patient experiences will be reduced to quantifiable fragments, disregarding aspects that are not quantified or identified in codified questionnaires, but may still be very relevant.…”

Historical foundations and contemporary expressions of a right to health care in Circumpolar Indigenous contexts

“…The method we chose is to review published and gray literature, including legislation, policies, and government reports for each state under study, and related policy studies that might shed light on the implementation of such policy. Policy document analysis is a widely accepted method for tracking policy implementation (see e.g., Lavoie et al, 2013;Jones et al, 2017;Munthe-Kaas et al, 2019;Steinmann et al, 2020). We searched for documents publicly available online.…”