It is evident that health is going through an unprecedented crisis, which was intensified with the pandemic, and there is a need for change, questioning the possibility of a value-based health model. Brazil is going through a scenery Record accident rate and the carriers registered an operating loss of R$ 10.7 billion in 2022. One of the main structural factors that ultimately lead to this inefficiency scenario is the Fee for service, the predominant model that pays based on the service, prioritizing the number of procedures rather than clinical outcomes.
The existing conflict of interest between the operator and the service providers can be summarized as follows: on the one hand, operators, in order not to have a very high operating cost, want to reduce the use of the accredited network; meanwhile, in Fee for service, providers, such as hospitals, are paid per procedure performed, which makes it financially advantageous to carry out several procedures. According to IESS (Institute for Supplementary Health Studies), from 2014 to 2019, the number of care procedures increased by 19.6%, despite a 6.1% drop in the number of beneficiaries during that period. The Institute also highlights a survey in the magazine Consumidor Moderno that identified Brazil as one of the countries that perform the most medical exams in the world.
Given this crisis scenario, discussions are growing about possibilities for more sustainable and efficient models for health. Among them, there is a highlight of the debate about Value Based Healthcare (VBHC), which would be a model whose compensation is based on the clinical outcome and completion of treatment, evaluating the patient's quality of life after the entire procedure. It is understood that this model would lead to more efficient resource management and would avoid the waste characteristic of Fee for service and would be more transparent with the health result delivered to the patient, in addition to possibly stimulating an interesting competitive scenario by linking payment to result.
O Value Based Healthcare In the world
The model of Value Based Healthcare was initially developed in the book “Rethinking Health: Strategies to Improve Quality and Reduce Costs” by Elizabeth Teisberg and Michael Porter. However, there are some challenges that vary within each country. In an article published in 2020 in the magazine NEJM Catalyst, researchers conducted an analysis of different health systems - in Massachusetts (USA), the Netherlands, Norway and England - addressing structural differences between them and the variations in the programs used to generate value in health, gathering insights about some challenges and about the implementation of the model of Value Based Healthcare around the world.
The article highlights that in the last 15 years, various health systems in the world have begun to adopt VBHC agendas, for different reasons and using different foundations, so that the role of governments, providers, and private payers varies. In the United States, for example, researchers indicate that initiatives to adopt the model of Value Based Healthcare are more linked to the removal of Fee for service and your waste. Meanwhile, in Europe, delimited by more public systems, there is a greater focus on coordinating patient care between providers and improving the quality and appropriateness of care.
It is highlighted by the study that no country fully implemented the VBHC agenda, but it was assessed by the researchers that the elements of the theoretical framework of the model seemed to work better in some health systems. The study showed that systems administered by the government tend to be more successful in starting centers of excellence. In short, the diverging interests between private providers hinder the adoption of value-based systems, and government involvement in the organization of care is a key element. Another challenge raised is the importance of IT infrastructure for integrating systems and measuring results throughout the entire service cycle, which did not show such good results in systems administered by the government.
Finally, the last point highlighted was the establishment of a VBHC culture among providers, which meets the current mentality that is still undergoing a maturation process. This mentality is still very focused on Fee for service, in which illness is the recipe model. Despite the implementation of the top-down structure (Top-down) being a trend, the study highlights that there is a risk of resistance coming from important parties, such as doctors, who need to engage in this implementation. The researchers stress that to overcome this resistance and involve the medical community in a possible model change, the VBHC culture needs to be more widespread.
The scenario and challenges of Value Based Healthcare in Brazil
In 2019, ANS released a Guide for Implementing Value-Based Compensation Models, talking about some challenges and possible measures to deal with them. In addition, the agency has also focused on stimulating debates on the topic in the sector and supporting operators with innovative value-based compensation projects. However, a guideline has yet to be implemented by the government to change the system model, which was built around the fee for service.
In the ANS Guide, the following challenges for implementing VBHC models are highlighted: resistance of service providers to a different payment model; risk of implementing an innovative model without a certain level of organization, which may impact the quality and safety of services; absence of information systems; the need to train the professionals involved and structure an efficient health service management system that monitors health indicators, among other points.
In addition, the ANS indicates some problems with regard to the design of the new compensation model, such as the impossibility of covering additional costs that are part of the transition to the new model, the lack of financial reserves to manage increased risk, the lack of data, and the lack of interest in making the necessary changes to be successful in improving quality. However, the agency also highlights some necessary paths in favor of this transition to improve the entire system, which are: the involvement of providers in the construction of the project to implement the new compensation model; the standardization of projects and measures adopted; the granting of permission to providers when accessing the data determined by the operator about the care their patients are receiving; the reduction of higher financial risks for providers at the initial time of the implementation of the new model; and, finally, the review of contracts that establish barriers to incorporating the new model.
