Dr Alfonso PICCOLI
HEAD OF THE DEPARTMENT OF INTERNAL MEDICINE AT THE SAN ROCCO CLINICAL INSTITUTE IN OME (Brescia)
In order to respond to the increasingly complex challenge of meeting the population’s needs for healthcare without increasing costs, while maintaining the quality and innovation of the treatments offered up until now, Value-based medicine (VBM) has slowly gained popularity, alongside the well-known approach on which Evidence-based Medicine (EBM) is founded. We talk about this with Dr Alfonso Piccoli, head of the Department of Internal Medicine at the San Rocco Clinical Institute in Ome, Brescia (one of the 37 facilities of the San Donato Group), and member of the Agenas Register of experts (National Agency for Regional Healthcare Services).
Dr Piccoli, what are the factors that are currently leading healthcare operators to adopt this basic change in mentality?
“The gradual ageing of the population, the increase in the incidence of chronic illnesses and the sustainability of the system are three of the most important social economic and demographic factors that have caused considerable problems for healthcare systems all over the world. It is being worked on to tackle acute episodes, but is still not “effectively” equipped to take responsibility for patients’ long-term care. Additionally, many clinical trials, despite being conducted correctly, present limits with regard to the selection of the populations to be considered and of the co-morbidity (the simultaneous presence of several illnesses in the same patient, ed) entered and the chosen result indicators do not always consider the value expressed by the patient”.
What does Value-based Medicine propose?
“The crucial requirement for the application of this clinical decision-making method is to assess the result and the quality of the entire course of treatment. Both through clinical result indicators that are scientifically valid and easy to use in daily practice, and by considering the value that the operation itself has in terms of cost effectiveness and above all patient satisfaction”.
What exactly is value-based medicine?
“It can be defined as the practice of medicine that incorporates both the highest level of data based on evidence and the value perceived by the patient generated by the healthcare interventions for the resources spent. Value-based medicine is based on the fundamental concept that, in order to improve the quality of treatments while maintaining their economic sustainability, it becomes necessary to redefine the nature of competition in healthcare, aligning it around the concept of maximising the value for the patient. Therefore, value can be defined as the best possible ratio between the optimum result of the treatments (or rather the restoration of the best possible condition of health) and the cost sustained to generate such a result. Without these considerations we should not be surprised by data such as the failure of patients to follow courses of treatment on the highest level of EBM scientifically speaking, but with the risk that the patient doesn’t appreciate these ‘as his own’”.
Instead, what is meant by value-based healthcare?
“The term value-based healthcare, first coined by Michael Porter, American academic and economist, professor at the Harvard Business School, and Elizabeth Teisberg, professor at the Dell Medical School, University of Texas, embraces the concepts of continuously measuring the results of health and the costs sustained to achieve them. The numerator is specific for each clinical condition and closely linked to the scientific know-how, while the denominator is the total cost measured not based on the single intervention, but on the entire cycle of treatments. Value equals the sum of the results (clinical effectiveness, the sick person’s history, safety) and the resources (management costs, capital costs, non-financial costs).”
Does value-based medicine also focus on the values of the patients? If yes, which ones?
“There are many, including the increase in the patient’s life expectancy and the higher quality of life related to good health (Health Related Quality of Life – HRQoL). The increase in life expectancy can be easily measured using real indicators such as the survival rate. Measuring the HRQoL improvements is possible using tools based on the functions (such as, for example, the general levels of physical activity, the evaluation of reported experiences – PREMs – and outcomes – PROMs) and based on the preferences defined as utilities”.
Value-based medicine: how can it be favoured in practical terms?
“Essentially by overcoming the silos approach. By organising, especially in the fields of internal medicine and chronic illnesses, the provision of healthcare services around certain clinical protocols when a condition can include several illnesses and associated complications. The identification of a dedicated multi-disciplinary team, a figure responsible for the entire treatment cycle, a pathway of prevention, diagnosis, treatment, rehabilitation, monitoring, dedicated infrastructures and integrated operational management is certainly useful. But that’s not all: developing result and cost indicators that are valid and easy to use for assessing the clinical practices, moving the focus from the volume and profitability of the individual services towards the results obtained by the patients and defining validated and specific indicators for each condition and not for the individual intervention or the individual clinical episodes”.
By: Tommaso Revera
Translation: TDR Translation Company
Editing: Victor Cojocaru