PUTTING patient outcomes “front and centre” was the key to making the cultural shift from volume-based to value-based health care, say health leaders.

Dr Dan Ewald, a GP on the NSW North Coast and Lead Clinical Advisor at the North Coast Primary Health Network (NCPHN), told InSight+ that cultural change was “enormously challenging” and would take time, but the improvements in patient outcomes would be worth it.

“We all care about the patient outcomes and, if you put that front and centre, it’s a different conversation than if you are just in a hospital management hierarchy saying ‘you need to improve cost efficiency or address clinical variation’,” he said.

Clinicians across all sectors also had to recognise the importance of working not just for the patient but on improving the system, he said.

“We need the system to be flowing so it’s easy for the patient to transition in and out of specialist care and back into general practice care,” he said.

Dr Ewald was commenting on a Perspective published in the MJA, written by NSW Health leaders.

Secretary of NSW Health Elizabeth Koff and Deputy Secretary Dr Nigel Lyons said that, as with all health care systems, NSW Health was experiencing growing pressure from chronic disease, an ageing population, and the use of new technology.

“Delivering health care is increasingly complex and demanding,” they wrote. “Identifying and unlocking the value that exists in every aspect of the health system is a long term aspiration. It requires greater maturity of systems and the collective efforts of clinicians, health executives and managers.”

Value-based health care, they said, sought to deliver value across four domains: improved health outcomes, improved experiences of receiving care, improved experiences of providing care, and better effectiveness and efficiency of care.

They pointed to the Leading Better Value Care initiative as the flagship program in driving this change. The program has several initiatives, including the osteoarthritis chronic care plan, the osteoporosis re-fracture prevention program, diabetes high risk foot services, and chronic wound management programs.

Dr Ewald said a disease-centred focus had helped to engage clinicians in the change process.

“The [targeted areas] are mostly high volume conditions … where the gap between evidence-based practice and actual practice is pretty obvious,” said Dr Ewald, who has been involved in the development of several Leading Better Value Care topics in his area.

He said identifying conditions in which there could be some “fairly easy wins” had helped to bring clinicians to the table.

“Building the clinical leadership is a key, and often not well done, step [in this process],” he said.

The flipside to focusing on specific conditions, Dr Ewald said, was whole-system reform in delivering value-based, patient-centred care.

“The implementation needs to have a major emphasis on the whole health system, not just on the body part,” he said.

Dr Ewald said NSW was off to a good start in moving to value-based care, but the cultural changes required remained “enormously challenging”.

“I applaud NSW Health for doing this work,” he said. “The cultural change is always the hardest stuff. We know that you may need to chip away for many years to shift the culture.”

Dr Sidney Chandrasiri, Group Director of Academic and Medical Services at Epworth HealthCare, said designing systems to achieve optimal value for every resource used was fundamental to achieving a truly sustainable health care system.

“The issues highlighted in the [MJA] paper reflected the urgency required to achieve such a transformation. A failure to proactively plan for adequately addressing these types of emerging challenges has already led to a compounding of their consequences,” said Dr Chandrasiri, pointing to unwanted clinical variation, exorbitant out-of-pocket costs, extensive wait times, and inequitable access to health care for many Australians.

She said practical barriers to implementing value-based care included the absence of advanced, interconnected IT infrastructure and data sharing capability across both the states and nationally, which was compounded by geographical challenges.

“There needs to be a reassessment of our current funding models, an assessment of our capability for statewide clinical services planning and willingness to embrace transformation and significant change. More fundamentally, there needs to be collaboration and cohesion amongst the various health system stakeholders to shift the collective mindset from volume- to value-based health [care] models.”

The significant upfront investment – in terms of personnel and infrastructure – for long term gain presented a further hurdle, she said.

“Engaging our clinicians in viewing their clinical service delivery through a value lens will be imperative as it is likely to be quite confronting to most and will pose a particularly challenging barrier to this change.”

It’s a challenge that the NCPHN, together with the Northern NSW Local Health District, has taken on in the development of its Winter Strategy, which is about to enter its fourth year.

Under the program, about 800 patients identified as being at high risk of hospital admission during the influenza season are registered with their general practice and monitored throughout the winter months. Should a hospital admission occur, the GP is notified and is able to “reach in” to the hospital system to discuss care. Discharge notices are also promptly provided to the GP.

Both clinicians and patients involved in the program reported improved experiences. While the impact on hospital admissions has yet to be measured, the final evaluation reported that the program had a positive impact on the local culture of integrated care.

Dr Chandrasiri said a key principle of value-based health care was taking a patient-centred approach to generating value over a full cycle of care, from the hospital admission and coordinated postoperative follow-up, to ongoing disease management and preventive measures.

“Adopting a full care cycle approach to disease management, as opposed to how our current system is structured – by specialty group or by discreet interventions provided – will inevitably require primary care systems, hospital systems and outpatient/specialty care systems to align and cooperate in working together towards a common goal.”

Dr Ewald said an exciting consequence of NSW Health’s move to embrace value-based care was its potential impact on private sector care.

“I would hope to see a spillover effect of quality [health] care from the public sector into the private sector.”

He said when patients experienced evidence-based, integrated care in the public sector – such as conservative management of knee osteoarthritis before considering a knee replacement – they would come to expect that same approach in the private sector.

5 thoughts on “Value-based health care: putting patients “front and centre”

  1. Ben Killen says:

    I work in an Exercise Physiology business. From my perspective, this is where Allied Health can play a huge role in the value-based healthcare approach.

    We are personally trying to resolve this issue as best we can. We have come up with what we feel is an appropriate value-based solution for a chronic disease management plan for patients. It provides them with a far more comprehensive introduction to conservative management, with the aim of showing them the benefits of exercise for their condition to allow them to take ownership. It requires strong communication with the general practitioner and allows us to leverage the amount of time we spend with the patient to reinforce key messages that the doctor will send through. Due to our close working relationship with Musculoskeletal professionals (surgeons, sports doctors etc.), this messaging is easy to get right.

    In my opinion, solutions like this are very feasible given our current system. There are thousands of allied health professionals who are silently crying out to be able to create something like this. All it takes is the willingness of medical professionals to communicate and allow the Allied Health services to help solve their problems. In our experience, this has worked tremendously well & is something we firmly believe is the future of healthcare.

    FYI if interested our website is: http://www.mtphealth.com.au

    Please don’t hesitate to reach out if you have any thoughts on our approach. We are incredibly passionate about making a real change!

  2. Carolynne Bourne says:

    A paper to the Parliament of Australia Select Senate Committee is available for viewing at “Sub244_Bourne and Associates Replacement.pdf”

    We propose two mechanisms that singularly, and jointly, effect the health and well-being of patients (please see diagram in the aforementioned paper):

    1. The External Mechanism
    2. The Internal Mechanism

    Both mechanisms require addressing/change to existing practices.


    “Medical practitioners may select to develop their knowledge and skills in an ever restricted discipline within a defined field of medicine ie medical oncologist, surgeon.

    In this scenario, specialisation in health care, in both education and workplace environments, has led to fragmentation.

    In pragmatic terms, a specialist can focus their particular skills and knowledge to identify and solve health care problems quickly and effectively and apply related interventions and treatments. However, the downside is that the specialist may only treat the patient in his/her own restricted discipline – a ‘silo mentality’. I would go further and add to the ‘silo mentaiity’, the term ‘dismember mentality’.”

    “Whole-of-person: To assist in breaking down the silos ie the culture and related attitudes and behaviour within the medical profession and education environments needs to be changed.

    Fund programs that focuses on the fundamental problem, ‘lack of communication’ • specialist to specialist to other health professionals • specialist to GP • specialist to patient encompassing basic human kindness, mutual respect and information
    sharing across disciplines as needed that is learnt and practised at:

    • Undergraduate levelCurriculum that includes communication supported by applying the learnings to patients ie through ward rounds, as well as a culture where attitudes are of mutual respect.

    • Specialisation level. Professional development activities linked to registration/accreditation requirements.”

  3. Anonymous says:

    There is an unchallenged assumption that when the agitators among us insist on change (sometimes but not always for quite laudable motives) they neglect to consider that change is not necessarily for the better. That changes can make things worse.

    In primary care at present, there is a perverse incentive to churn which is due to the decades long freeze on Medicare rebates coupled with the a deliberate flooding of the market with foreign-trained doctors (I am one of them, so don’t be calling the racist card).

    The churn incentive is now being replaced with the care-plan scam. Nurses interviewing the patient and printing off a computer-generated multi-page piece of drivel that is of less use to the patient than a piece of shiny toilet paper. I may have not met them yet, but I have not come across a single GP who uses the care-plan billing item number appropriately to produce something that make sense to the patient, and adds to the patient’s clinical care.

    Now we have two more UK-originated schemes: the electronic health record, and a capitation system of payment that rewards registering a patient, and then disincentives actually seeing them.

    Now if proponents of change actually started out by considering the myriad ways in which their schemes can run off the rails, be subverted or generate unintended consequences, we might at least remain stationary instead of perpetually degrading our profession and the care we are able to offer.

  4. Brian mcCaughan says:

    These programs emphasise the critical role of the Agency for Clinical Innovation in achieving the appropriate outcomes

  5. Dr Duncan MacKinnon says:

    The ideal process for the OACCP would be for the patients GP to refer them to the program before referring them to the Orthopaedic surgeon. The problem is that community health doesn’t have the workforce to deal with the volume which means they already have an RFA and the patients expectation is for a surgical fix!
    Maybe there could be a public/private OACCP partnership to mobilise community physiotherapist resources with seed funding provided by NSW Health.

    On another issue, the cultural change that needs to occur is for specialist colleagues to consider the patients GP as part of the health care team. Consultants often don’t, and their juniors learn by example so that the clinical handover occurs too late, is in the form of a low-quality discharge summary or not at all.
    When I refer an unplanned episode of care to A&E, I write a letter, order appropriate investigations and ring the admitting officer or NUM to do my clinical handover. In return, the same should occur in reverse at least in the case of unplanned acute admissions. Patient-centred care is simply a matter of respect for the individual and is directly related to better value care. The cultural shift that has to happen needs to be led from the top within NSW health and modelled effectively.

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