While value is a central concept in VBHC, it seems from the studied hospital implementation that the perception of value is different among the different stakeholder groups. While both clinicians and non-clinicians talked about value as a construct consisting of both outcome and costs/resources spent to achieve those outcomes, there was an imbalance in the perception of value. The majority of respondents did not appear to focus much on costs or cost containment, even though it is considered as important an objective as improving outcomes within the original VBHC framework. Clinicians talked about value as a dynamic concept depending on the view of the patient and the context, and put forward that better outcomes sometimes require higher cost/more resources. In contrast, non-clinicians’ perception of value appeared to be more aligned with the VBHC framework. While many interviewees indicated that the deficiencies of the current accounting systems hamper understanding of the cost, our interpretation is that there is a clear discrepancy between the concepts of value within these stakeholder groups. In light of this, creating a common understanding of the value concept in order to co-create understanding and contextual dialogue may be pivotal for future implementation processes of VBHC.
The uncertainty introduced by the ambiguous term “value” may present an obstacle to organizations attempting to manage a shift in how they operate, as the ambiguity may introduce friction between professional groups, management, and between patients and providers. Paradoxically, this uncertainty around what value means could also be an opportunity and a way of integrating the different perceptions among the multiple stakeholders, as outlined in this study. A recent study by Nilsson and Sandhof [29] shows the importance of goalsetting, role description and leadership expectations when implementing VBHC, which in previous implementation research has been described as contextual dialogue with the aim of managing understanding[30]. Bååthe and Norbäck[30] present how professional identifies need to and can be modified and they outline an alternative to the prevailing managerial control perspective. Further, they suggest that the manner in which the contextual dialogues are being carried out is what determines if this ambiguity can be considered an obstacle or an opportunity to creating more integrated ways of understanding value for all the stakeholders. Scott [20, 31] argues that professional groups are the most important carriers of institutional ideas because they apply these ideas by defining and interpreting them into the context and situation. It should therefore not be taken for granted that people involved in a change process share the same goals, commitment or understanding of the concept being implemented [32, 33]. Hence, the institutional logic of management may struggle to be infused into everyday practice due to the lack of symbols related to the relationship between outcome and cost (efficiency) within the current environment. Non-clinicians expressed the view of value closest to the original definition of Porter, speaking more in terms of efficiency and balance between outcome and cost. In light of this, the future implementation process of VBHC should take this discrepancy into consideration and create a common understanding of the value concept in order to co-create understanding and contextual dialogue.
Traditionally, the logic of medicine, which is driven by improving outcomes and treatment efficacy, is considered the most influential and powerful. This could impact the chances of other logics to be heard in both the strategic and operational levels of VBHC, for example, the logic of care (such as nursing) or the logic of control (such as managers). We therefore argue that the implementation of VBHC needs to balance different logics, and not least give room to further listen to the patients’ voice in this co-creational change process[23].
The present study raises some questions regarding VBV and the patients’ perspective of value. From the quantitative analysis it appears that neither cost of the admission period nor the VQ correlated well with patients’ perceived value of the care. Using the VQ may therefore not necessarily result in care valued higher by patients, even when such care is more efficacious due to improved outcomes and/or lower cost. This finding is supported by Porter and Lee [34], claiming that there is no known correlation between cost and patient perceived value. As the value quota is calculated as a ratio between outcome and cost, this raises the question of the relevance of the value quota as a tool. While the value quota case in this paper only serves as an example, employing a validated and highly cited HrQoL instrument, we argue that it is challenging to find practical usage of the value quota.
Literature on consumer value has argued the definition of value implies a trade-off between benefits and sacrifices[11], and our findings could imply that the patients in our analysis do not acknowledge value as a trade-off between outcome and cost. This finding particularly makes sense in Sweden, where the healthcare system is “free for the patient” while financed nationally via income tax. Patients are not aware of the related costs involved in creating the experienced individual outcomes.
It could be argued that patients within the Swedish context perceive the concept of value as a process indicator of care rather than the outcome of the care provided. This argument is in line with other scholars arguing that the patient perceives value as the interaction and relational aspect between the provider and the patient [12, 35] rather than only the outcome of a treatment. Patient value may not be solely dependent on outcome and cost for all patients [36, 37]. It is highly unlikely that all patients would value the same measure of outcome of a care episode. It has been argued that patients lack the motivation and the opportunity to make sense of the interplay between quality and price/cost in healthcare[35]. As the patient in VBHC is described by Porter as acting as a “consumer” who chooses the best provider based on outcome or cost, our findings might indicate an inherent barrier to this. We would argue that there are really no consumers of healthcare, just individuals seeking medical, nursing or other healthcare services. The logic of the patient may not be transferable to the underlying assumption of a customer being both able and willing to compare value for money, i.e. price-performance ratios provided by different healthcare providers. From a European perspective, there is insufficient evidence that patient choice as a competitive driver in healthcare has improved outcomes or reduced cost [8, 9].
Our findings suggest that when patients are asked about value with the single question “How would you value the overall care provided?”, the answer is not associated with outcomes or cost. And while one could debate the sensitivity of a single question, we believe that for patients, value is a complex interplay between outcome and relational experiences, including feelings of security and respect, former experiences and future expectations. A recent systematic review has shown that patient experience of care is positively associated with quality of care and a reduction of adverse events[38]. Thus, a one-sided focus on medical/economical outcome could be sub-optimal in improving care, as perceived by patients.
A single-minded focus on outcomes could therefore result in missing the target. While the voice of the clinician is important, it could be argued that the voice of the patient must be considered in practice in order to design a framework for a sustainable healthcare model that is person-centred [39, 40].