Translating value‐based health care: an experiment into healthcare governance and dialogical accountability

Abstract

This article analyses an experiment into healthcare governance in Denmark inspired by principles of value-based health care and intended to re-orient the focus of healthcare governance from 'productivity' to 'value for the patient'. The region in charge of the experiment exempted nine hospital departments from activity-based financing and accountability based on diagnosis-related groups, which allegedly incentivised hospitals in 'perverse' and counterproductive ways. Instead, the departments were to develop new indicators from their local practices to support and account for quality and value for the patient. Drawing on the actor-network theory concept of 'translation', this article analyses how the experiment was received and put into practice in the nine departments, and how it established new kinds of accountability relations. We argue that the experiment provides fruitful inspiration for future governance schemes in healthcare to embrace the local complexities of clinical practices. In particular, we argue that the locally developed indicators facilitated what we call 'dialogical accountability', and we discuss whether this represents a feasible way forward for value-based health care.

Weak Data: The Social Biography of a Measurement Instrument and How It Failed to Ensure Accountability in Home Care

“…It is in line with what is typically called value‐based care (Bonde et al. 2018). Unfortunately, the required measurements create a lot of data work.…”

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

“…The conceptual ambiguity surrounding VBHC is conspicuously evident in academic publications. To some scholars, VBHC is primarily a 'management concept' [1] or a 'management innovation' [2,6]; to others, it is basically a business 'strategy' for both providers and payers [7]; others see it as a 'governance regime' [3], or a 'health policy framework to integrated care' [8]. Additionally, while the importance of outcome measurements for VBHC is generally well established, the range of its utility remains debated.…”

“…In fact, the observation that the implementation of VBHC requires the concept to be 'translated' (i.e. adopted and adapted) into multiple local contexts is indeed brought forth to explain the ambiguity [2,3]. Another, perhaps slightly provocative explanation, is that the meaning of VBHC is being diluted due to a lack of understanding by knowledge producers, particularly within academic writings [1].…”

“…Today's remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. Several scholars have noted this ambiguity, with explanations ranging from the concept being diluted in academic literature [1], to VBHC being a highly ambiguous concept in and of itself [2], and to VBHC being adopted and adapted within various local contexts [2,3]. This paper elicits an alternative conception.…”

Walking the tightrope: how rebels “do” quality of care in healthcare organizations

“…Quality improvement in healthcare is increasingly concerned with the standardization of professional behaviour and organizational routines. Starting with the "discovery" of practice variation in the 1970s, methods such as clinical guidelines, accreditation, quality registries and performance indicators have been developed to make healthcare practices increasingly measurable, comparable and governable (Bonde et al, 2018;Wallenburg, Quartz and Bal, 2019;Weggelaar-Jansen et al, 2018). This "system" approach to healthcare has been fostered by the release of the "Institute of Medicine (2000)" report in and its numerous follow-up accounts about the importance of improving quality of care through building organization-based systems of quality control and improvement.…”