In the health system of Iran and most countries, the common payment model is still "fee-for-service ", but this is not the best revenue model for providing health services, because when the income of health service providers is reduced by the number of services and measures that they do is determined, the quantity of service provided is preferred over its quality. In this way, health care workers have little motivation to achieve the best result in the shortest time, and for this reason, this method is not suitable for managing the costs of the health system. The payment model that has gradually found its place is "value-based care " .
Let us use an example to clarify the difference between the two mentioned payment models. Suppose a 45-year-old patient with a history of smoking comes to the medical center complaining of fever and cough since 3 weeks ago. The doctor first examines him and then requests diagnostic tests and lung radiography. Finally, it is determined that he has a lung infection (pneumonia) and the doctor decides to admit him for injectable antibiotic treatment according to the patient's condition. After a few days, with the improvement of the patient's symptoms and tests, he is discharged.
When costs are calculated using the fee-for-service method, the patient incurs a fee for each procedure performed on him, including examinations, blood tests, chest x-rays, serum therapy, hospitalization, and hospital stays. Hospital personnel, i.e. doctors, laboratory technicians, nurses, etc., receive a specific amount for the work they have done for the patient. Now, if the patient returns to the treatment center after discharge due to recurrence of symptoms, the costs for him will be calculated in the same way.
But in value-based care, what matters is the outcome of the actions taken for the patient and their impact on their health. In this method, the doctor examines the patient and may request the same diagnostic measures, but when he has to choose a treatment method for his patient, he must also consider the long-term results. For example, hospitalization increases the risk of acquiring hospital-acquired infections. Therefore, the doctor compares the advantages and disadvantages of injectable antibiotic treatment in the hospital with the oral antibiotic prescription and may decide to treat the patient on an outpatient basis instead of admitting him and to ensure his treatment process on a daily basis by using the patient's telemedicine services. to visit
In value-based care, the patient's recovery and health are evaluated. If the treatment team is able to make decisions that the patient recovers earlier than the usual time, does not come back with the same previous complaint within a specified period of time, and the patient is satisfied with the treatment conditions, they will receive a reward according to the excess benefit they have created for the health system. they do. But if the measures taken impose additional costs on the health system, for example, the patient gets a hospital infection during hospitalization and his condition becomes complicated and he stays in the hospital for two weeks longer than usual, as a penalty, an amount will be deducted from their prescribed salary.
In addition, in value-based care, health service providers are responsible for promoting the health of the community they cover, and preventive care is of great importance. Therefore, in the above example, the treatment center is expected to have previously advised the patient about quitting smoking and helped him to quit. Also, his disease was diagnosed and treated in the early stages so that he does not need to go to the emergency room.
As mentioned in the example above, part of the services expected from health centers in value-based care are similar to the tasks that health centers in our country are responsible for. Health care providers should spend more time assessing the health of their clients, finding and managing other risk factors that people may not mention, and screening and diagnosing various diseases. With the difference that in value-based care, private indicators are defined so that health managers can measure the results of the actions taken and the improvement of the health of the covered community. Health care workers are also evaluated based on these indicators and receive wages.
Challenges of value-based care
Value-based care has many benefits for all health stakeholders, as mentioned earlier, but its implementation comes with challenges, which we will discuss below. The following are the results of Definitive Healthcare 's survey of 791 healthcare executives in the fields of service providers, biotechnology, financial services, human resources, information technology, and more.
Difficulty in collecting and reporting patients' information: evaluation of measures and services in this method is highly dependent on the individual's health information. From background information and past care to treatment adherence and post-treatment conditions. Collecting and accessing population data is one of the biggest barriers to transitioning to value-based care.
Lack of cooperation inside and outside the organization: There are many data and analyzes about various factors affecting people's health scattered in different organizations. Implementation of the new payment model requires coordination between the existing tools and the adaptability of their data.
The complexity of risk assessment and the unpredictability of the income stream: Another problem of implementing the value-based payment model is the uncertainty of the income stream as well as the complexity of the risk assessment.
Lack of resources: According to the survey, the most important obstacle to the implementation of value-based care is the lack of human resources, the lack of appropriate health information technology software, and the lack of infrastructure.