By Soham D Bhaduri
Recently, the National Health Authority (NHA), which steers the Pradhan Mantri Jan Arogya Yojana (PMJAY), released a policy document titled Volume-Based to Value Based Care: Ensuring Better Health Outcomes and Quality Healthcare under AB PM-JAY. It proposes moving on from the existing input- and volume-based system of reimbursing care to one based on outcome, quality, and value—something experts have long clamoured for.
As evidence from multiple sources attests, poor quality healthcare in low and low middle income countries (LMICs) contributes more to treatable mortality than non-utilisation of health services. Poor quality care has worse implications for population health in LMICs than in developed countries, not just in terms of foregone health gains but also health spending inefficiencies.
In this regard, the Union’s renewed focus on value and quality in healthcare is highly commendable. However, a close examination of its strengths and weaknesses is merited since an emphasis on healthcare quality will constitute a fundamental pillar of India’s ambitious universal health coverage (UHC).
First, it is worthwhile looking at the basics. Value-based healthcare (VBC) has strong positive implications for overall health status, patient satisfaction, and healthcare costs, particularly in the current age of rising chronic diseases, rapidly progressing technology, and rampaging costs. One will agree that value is eventually all we want from healthcare, but value as such is elusive to definition. Theoretically, value would be estimated in monetary terms, as in how much money one is willing to pay (to get care) or receive (to forego care), but these don’t readily lend themselves to every-day clinical use.
A better suited indicator of value is therefore found in health outcomes, since it is axiomatic that anyone seeking health care is primarily motivated by health improvement. But outcomes, even if they yield to successful objective measurement, are not always correlated with the healthcare provider’s efforts. A common workaround, therefore, has been to pay providers through mixed modes that incentivise not just standardised, evidence-based outcomes but also efforts (for example, observance of clinical protocols and best practices).
One of the standout merits of the NHA policy document is its holistic approach to capturing value, which has been missed even by many advanced healthcare systems of the west. The document considers all three health system objectives described by the World Health Organization, viz. health status improvement, responsiveness to patient needs, and financial fairness, while defining measures of value.
Operationalising this idea of value will surely be more advantageous than counting health outcomes alone, particularly for UHC. Further, the selected indicators for value-based incentives are amenable to ready implementation on account of their simplicity and low resource-intensiveness.
There are some important shortcomings, however. Currently, PMJAY empanelled hospitals receive incentives of up to 15% based on their accreditation and quality certification status. The value-based incentives, rather than being additional, will gobble up half (7.5%) of this 15% incentive cap, the remaining 7.5% going to accreditation and quality certification. What this implies is that the overall quantum of quality-based incentives shall remain unchanged, and so this hardly alters the current status quo of case-based provider reimbursements. Further, we must remember that these incentives will only straddle hospitals empanelled under PMJAY, omitting the larger healthcare ecosystem. Unless the incentives are significantly augmented, transitioning to VBC will remain tokenistic and gimmicky.
Secondly, data on outcomes, beneficiary satisfaction, and out-of-pocket expenditures by patients will be collected by NHA call centres and Arogya Mitras. This introduces strong conflicts of interest, and will call for oversight by independent parties to safeguard transparency. Tools that rest greater control in the patient’s hands are needed. While the document espouses an uncompromising stance on frauds, such mechanisms can themselves provide opportunities for ‘gaming’ the system.
Another methodological issue is the use of the EQ-5D-5L questionnaire as a blanket instrument to assess outcomes across all morbidity and procedure categories. Used for estimating Quality-Adjusted Life Years (QALYs), this tool can only give a generic measure of treatment outcomes and is ill suited for granular assessments of specific conditions.
Worldwide, condition-specific Patient Reported Outcome Measures (for e.g., heart disease specific questionnaires) are frequently utilised for a more detailed window into outcomes and care personalisation. Their use will become imperative for a deeper transition into the VBC culture.
Lastly, the NHA document upholds a predominantly punitive culture that provides very little forward-looking support to institutions for improving quality. For instance, providers with any confirmed patient grievances will not be entitled to the corresponding incentive. How the institutions will be supported to improve quality, particularly in the public sector that is perennially short funded, remains a mystery. Evidence shows that a forward-looking organisational culture is pivotal to quality improvement.
As important as VBC is, it is not the same as quality healthcare. We need to appreciate that VBC is but one component of the holistic agenda of quality improvement—and that overarching systemic, organisational, and cultural reforms are needed to attain it. This holistic agenda is termed ‘clinical governance’, popularised after a spate of clinical failures in the UK during the nineties. It comprises ‘seven pillars’ which are commonly cited as clinical effectiveness and research, staffing and staff management, use of information, education and training, clinical audit, patient involvement and experience, and risk management.
All existing, fragmented quality improvement initiatives, including potential VBC systems, must be brought under an integrated national clinical governance framework. At the organisational level, this may translate into having dedicated directorates that oversee each pillar. Only this can embed a perpetual pursuit of quality in the Indian health ecosystem.
The writer is a Mumbai-based doctor & Editor of the journal The Indian Practitioner