International Journal of

Environmental Research
and Public Health

Review
Value-Based Healthcare Delivery: A Scoping Review
Mirian Fernández-Salido 1, * , Tamara Alhambra-Borrás 1 , Georgia Casanova 2 and Jorge Garcés-Ferrer 1

1 Instituto de Investigación en Políticas de Bienestar Social (POLIBIENESTAR)—Research Institute on Social

Welfare Policy, Universitat de València, 46022 Valencia, Spain; tamara.alhambra@uv.es (T.A.B.);
jordi.garces@uv.es (J.G.F.)
2 Centre for Socio-Economic Research on Ageing, IRCCS-INRCA National Institute of Health & Science on
Ageing, 60124 Ancona, Italy; g.casanova@inrca.it
* Correspondence: mirian.fernandez-salido@uv.es

Abstract: Healthcare systems are transforming from the traditional volume-based model of healthcare
to a value-based model of healthcare. Value generation in healthcare is about emphasising the health
outcomes achieved by patients and organisations while maintaining an optimal relationship with
costs. This scoping review aimed to identify the key elements and outcomes of implementing value-
based healthcare (VBHC). The review process included studies published from 2013 to 2023 in four
different databases (SpringerLink, PubMed, ProQuest and Scopus). Of the 2801 articles retrieved
from the searches, 12 met the study’s inclusion criteria. A total of 11 studies referred to value as the
relationship between the outcomes achieved by patients and the costs of achieving those outcomes.
Most of the studies highlighted the presence of leadership, the organisation of care into integrated
care units, the identification and standardisation of outcome measures that generate value for the
patient, and the inclusion of the patient perspective as the most prominent key elements for optimal
VBHC implementation. Furthermore, some benefits were identified from VBHC implementation,
which could shed light for future implementation actions. Therefore, the VBHC model is a promising
approach that may contribute to an improvement in the efficiency and sustainability of healthcare.

Keywords: health systems; healthcare; value-based healthcare; integrated care; older patients

Citation: Fernández-Salido, M.;

Alhambra-Borrás, T.; Casanova, G.;
1. Introduction and Background
Garcés-Ferrer, J. Value-Based
Healthcare Delivery: A Scoping
Population ageing characterises one of the most important transformations in devel-
Review. Int. J. Environ. Res. Public oped and emerging countries ever since the middle of the last century [1,2]. Along with
Health 2024, 21, 134. https:// a progressive increase in older people (65 years of age and older), the development of
doi.org/10.3390/ijerph21020134 chronic conditions (multimorbidity), which increase with increasing age [3–5], has become
a challenge for the provision and financing of healthcare and social services. In this regard,
Academic Editor: Dean G. Smith
health systems aim to address one of the main concerns about citizen care: the effectiveness
Received: 15 December 2023 of healthcare outcomes [6]. In this field, effectiveness is a term that addresses both the
Revised: 23 January 2024 quality of care and the optimisation of care processes [7,8]. Healthcare organisations are
Accepted: 24 January 2024 currently facing increased pressure on their total expenditure, the increased complexity of
Published: 25 January 2024 people’s health status, and the increased democratisation of therapeutic interventions [9].
In this respect, several studies on the historical development of healthcare have
recorded the various changes in the doctor–patient relationship and in the healthcare
model [10,11]. In the traditional medical model, the patient is reduced in his or her rela-
Copyright: © 2024 by the authors.
tionship with the health system and health professionals to a passive subject and a generic
Licensee MDPI, Basel, Switzerland.
person, i.e., without history or context. This model of healthcare began to be redefined in
This article is an open access article
the 1970s [12–14]. Since then, various proposals on the therapeutic relationship, guided
distributed under the terms and
by the principles of quality, safety, and symmetry, have promoted an increasingly human,
conditions of the Creative Commons
Attribution (CC BY) license (https://
ethical, and social interpretation of the patient [15]. The application of these propositional
creativecommons.org/licenses/by/
visions has resulted in care provision models moving from ‘patient-centred care’ [16] to
4.0/).
‘person-centred care’ [17]. Moreover, the services of today’s healthcare organisations take

Int. J. Environ. Res. Public Health 2024, 21, 134. https://doi.org/10.3390/ijerph21020134 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2024, 21, 134 2 of 19

into account, as a reference point in the provision of care, both costs and satisfaction, as
well as the active participation and experience of the population to be cared for [18–20],
leading to a new ‘value-based model of healthcare’.
This new paradigm of Value-Based Healthcare (VBHC) is presented as the optimal
alternative to the current care approach to health services, the volume-based healthcare
model [21]. The proposal of the VBHC model responds to the need to address the costs
of health services in relation to their capacity to improve the situation of patients [22].
This need is one of the main challenges facing healthcare organisations today, given the
limitation of public resources and the growing complexity, diversity, and plurality of the
health status of populations [23,24]. The value-based model of healthcare addresses these
material, socio-demographic, and care challenges or constraints of contemporary health
provision with a holistic approach to the quality of health services [25]. In this sense, value
in healthcare is understood as the trade-off between outcomes and costs, by extension, as
the potential effectiveness of health services [26–28].
The volume-based model of healthcare operates with a quantitative approach to health
service provision. Thus, at the level of clinical performance, the capacity of consultations is
prioritised over the patients themselves, and the cost of provision is prioritised over the
quality of services [29,30]. As a result, healthcare organisations are delivering healthcare
that is increasingly efficient but more segmented by department and with less capacity
for improvement [31]. Faced with this clinical trend of the loss of person-centredness,
the value-based healthcare model is presented as a strategy that revitalises the active
role of the patient and the viability of health services. This new paradigm of healthcare
complements health economics with a qualitative and holistic approach to its administration
and provision to the population. Thus, it is proposed as a normative healthcare strategy
focused on the construction of the value chain of the care process [25]. Even though
different initiatives on VBHC have been implemented and analysed over the last few years,
there remains a lack of acceptance of the concept and a knowledge gap around the existence
of a consensus on the definition of the VBHC concept. This is due to a number of factors,
including variations among different health systems around the world and the paucity
of available data demonstrating the effectiveness of measures implemented under the
VBHC model [32]. There are different interpretations of value and of the key elements for
its successful implementation, as well as a multitude of initiatives advocating different
positive outcomes. Thus, this study strives to reduce this knowledge gap by bringing
together the relevant literature and hopefully laying the groundwork for future research in
this area.
Our study aims to explore and synthesise the existing knowledge, through a scoping
literature review, of the VBHC conceptualisation and the key elements and outcomes
of implementing value-based care in the healthcare context and to identify how these
may contribute to improving the efficiency and sustainability of the healthcare system.
Therefore, the aim of this study is to identify, compare, and summarise the findings of
the literature on the following: (1) the definitions of value-based care extracted from the
literature review; (2) the key elements of implementing/delivering value-based care into
the healthcare context; and (3) the main outcomes, in terms of improvement in the quality
of the care process, of implementing value-based care. Moreover, this scoping review aims
to explore and identify pertinent gaps that would be beneficial for guiding future studies.

2. Materials and Methods

A scoping review responds to a specific methodology of locating and selecting existing
studies on a specific topic, according to pre-specified eligibility criteria, in order to analyse,
synthesise, and report the results found, with the aim of answering a clearly specified
research question [33]. We adopted the guidelines of the PRISMA 2020 statement (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) for its relevance to this study,
Int. J. Environ. Res. Public Health 2024, 21, 134 3 of 19

as it is primarily designed to evaluate systematic reviews of studies assessing the effects of

health interventions, regardless of the design of the studies included [34,35]. In particular,
the PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide
the conduct of this review; the protocol of this scoping review has not been registered or
published [36].
The bibliographic reference management application Zotero was used to transfer the
studies identified in the electronic databases and eliminate duplicates. To maximise the
evidence recovery from the databases, the literature search strategy was based on the
PICO framework, consisting of the construction of the research question according to the
description of the following components: patient or problem of interest (P), intervention (I),
comparison (C) and outcomes (O) [37]. However, this study does not present an inter-
vention with which to compare value-based care, so component C is omitted, leaving the
format as PIO. Table 1 shows the PIO model.

Table 1. Elaboration of the research question using the PIO model.

Acronym and Components Description on Components

(P) Population Healthcare system at large
(I) Intervention Value-based care approach
Improving the efficiency and sustainability of
(O) Outcomes healthcare systems, that is to say, the overall outcomes
of care in terms of the quality of care.

After using the PIO model, the following research questions are presented:
Does the implementation of a value-based approach lead to an improvement in the
efficiency and sustainability of healthcare?
If so, which are the key elements and the related outcomes of implementing the
value-based care approach in the healthcare context?
In order to identify, select, and include relevant literature that answered the research
question, and to discard studies that did not answer it, inclusion and exclusion criteria
were defined. The following inclusion and exclusion criteria were used for study selection:

2.1. Eligibility Criteria

Inclusion criteria:
(1) Articles addressing the implementation of value-based care in the healthcare context;
(2) Articles published in the last 10 years (2013–2023);
(3) Articles published in English and Spanish;
(4) Articles published in scientific journals;
(5) Full and open access articles;
(6) Original or primary source studies that are descriptive, experimental, quasi-experimental,
cross-sectional, and longitudinal articles.
Exclusion criteria:
(1) Articles that do not address the implementation of value-based care in the healthcare
context or articles focused on a specific condition/disease;
(2) Articles that were published more than 10 years ago;
(3) Studies that were published in a language other than English and Spanish;
(4) Articles published in non-scientific journals or incomplete and non-open access articles;
(5) Secondary source studies, such as reviews and editorials.

2.2. Search Strategy

A scoping literature review was conducted according to the inclusion and exclusion
criteria above in the electronic databases PubMed, ProQuest, Scopus, and SpringerLink.
The databases were chosen for their international recognition and broad multidisciplinary
coverage, with the intention of retrieving articles relevant to the subject of the scoping liter-
Int. J. Environ. Res. Public Health 2024, 21, 134 4 of 19

ature review. According to the eligibility criteria, articles that included descriptors related
to the terms MeSH (Medical Subject Headings) and DeCS (Health sciences desCriptors)
were selected [38]. The terms value-based, care, health, and healthcare were identified
from the MeSH and DeCS descriptors and combined with a Boolean operator, as shown in
Table 2, to develop a database search to achieve the proposed objectives.

Table 2. Search with descriptor and Boolean AND operators.

Boolean Boolean Boolean

Descriptor Descriptor Descriptor
Operator Operator Operator
Value-based AND Care AND
Value-based AND Care AND
Value-based AND Care AND
Value-based AND Care AND
Value-based AND Care AND AND Cost
Value-based AND Care AND AND Quality of life

To reduce the risk of subjective interpretation and possible inaccuracies due to chance
errors that might have affected the results of the review, two independent reviewers were
involved in the selection of studies in the electronic searches [39]. Thus, after eliminating
duplicate records, we proceeded with the preliminary data analysis, which included a
three-stage selection process: the first phase based on selection by title, the second phase
based on selection by abstract, and the third phase consisting of reading the full text of the
studies selected by abstract. Each of the papers was assessed twice by two independent
reviewers following the inclusion and exclusion criteria set above. A third reviewer was
involved in the process when disagreement arose or consensus was not reached, making
the final decision.

3. Results
3.1. Screening Results
A total of 2.801 records were identified covering the time span of January 2013 to De-
cember 2023, of which 1.609 duplicate registrations were deleted. Of the 1073 records
obtained after eliminating duplicates, 439 records were identified in the title review.
After applying the exclusion criteria in the selection by abstract, 396 were eliminated,
leaving 43 scientific articles for full-text review. A total of 12 full text articles were
reviewed, all of which met the inclusion criteria and were included in the final list
of studies included for this research. To conduct and report this scoping review, we
used the preferred reporting elements for systematic reviews and meta-analysis scoping
reviews: PRISMA-ScR [34] (Supplementary Materials) together with the PRISMA 2020
flowchart [35] (Figure 1). Figure 1 presents the flow diagram, which was based on the
PRISMA 2020 declaration [35], that illustrates the scoping literature review process and
details the reasons for exclusion at each screening stage.

Preliminary Insights
A total of 12 studies were included for the scoping review. In terms of the method-
ology used in the studies, 10 of the 12 studies used qualitative techniques, either through
interviews or focus groups, and 2 other studies used a mixed methodology, combining
the use of interviews and questionnaires. The following table (Table 3) shows the PICOTS
characteristics for each of the studies included in the scoping review [40]. Table 4 shows a
summary of the results found from the analysis of the studies in the scoping review.
Int. J. Environ. Res. Public Health 2024, 21, 134 5 of 19
Int. J. Environ. Res. Public Health 2024, 21, 134 5 of 19

Figure 1. Flow
Figure diagram
1. Flow diagramfor
forour
our scoping reviewbased
scoping review basedonon PRISMA.
PRISMA. Note:
Note: Reason
Reason 1: Articles
1: Articles that dothat do
notnot
address the implementation of value-based care in the healthcare context or articles
address the implementation of value-based care in the healthcare context or articles focused on afocused on
a specific condition/disease; Reason 2: Articles that were published more than 10 years
specific condition/disease; Reason 2: Articles that were published more than 10 years ago; Reason ago; Reason
3: Studies that
3: Studies were
that werepublished
published in a language
in a languageother
otherthan
than English
English andand Spanish;
Spanish; ReasonReason 4: Articles
4: Articles
published in non-scientific journals or incomplete and non-open access articles; Reason 5:
published in non-scientific journals or incomplete and non-open access articles; Reason 5: Secondary Secondary
source studies;
source Resource
studies; Resource6:6:Duplicate.
Duplicate.

Preliminary Insights
A total of 12 studies were included for the scoping review. In terms of the methodol-
ogy used in the studies, 10 of the 12 studies used qualitative techniques, either through
interviews or focus groups, and 2 other studies used a mixed methodology, combining
the use of interviews and questionnaires. The following table (Table 3) shows the PICOTS
characteristics for each of the studies included in the scoping review [40]. Table 4 shows a
summary of the results found from the analysis of the studies in the scoping review.
Int. J. Environ. Res. Public Health 2024, 21, 134 6 of 19

Table 3. PICOTS characteristics of reviewed studies.

Reference Populations Intervention Country Method/Outcomes Timeframe Setting

Qualitative analysis by
Exploration of how the
conducting interviews over
Professionals of VBHC representatives of four pilot
three periods with 20 members A Swedish
Nilsson et al. [41] implementation teams in project teams experienced Sweden 2 years
of the VBHC implementation university hospital
a hospital implementing VBHC in
teams, with a total of
four different groups of patients
59 interviews conducted
Exploration of four pilot teams’
Qualitative analysis through
Professionals of VBHC experiences of improvements
in-depth interviews with A Swedish
Nilsson et al. [42] implementation teams in resulting from the Sweden 2 years
20 members of the VBHC university hospital
a hospital implementation of VBHC in
implementation teams
a hospital
Exploration of four pilot teams’
Qualitative analysis through
Professionals of VBHC experiences of improvements
in-depth interviews with A Swedish
Nilsson et al. [43] implementation teams in resulting from the Sweden 2 years
20 members of the VBHC university hospital
a hospital implementation of VBHC in
implementation teams
a hospital
Presentation of a plan for the European University
Members/professionals
Cossio Gil et al. [32] implementation of VBHC Europe Qualitative analysis 2 years Hospital Alliance
of EUHA
in hospitals (EUHA)
Exploration of the main
Members of VBQI teams Qualitative analysis with
hindering and/or supporting Dutch top clinical
Daniels et al. [44] in a large Dutch top The Netherlands semi-structured interviews with 5 years
factors in the implementation of teaching hospital
clinical teaching hospital 43 members of 8 VBQI teams
VBQI teams in hospital care
Presentation of a pragmatic A method for implementing
Members of step-by-step approach for VBHC VBHC in Amsterdam UMC Academic hospital in
Heijster et al. [45] The Netherlands 3 years
Amsterdam UMC implementation, developed and based on ‘experience-based the Netherlands
applied in Amsterdam UMC co-design’ (EBCD)
Mixed methods research using
Top- and middle-level online questionnaires and
Investigation of how HPOs in Argentina, Brazil, Healthcare provider
executives from semi-structured interviews with
Makdisse et al. [46] five Latin American countries Chile, Colombia, 2 years organisations (HPOs) in
70 healthcare provider a total of 70 participants from
were implementing VBHC and Mexico Latin America
organisations (HPOs) health organisations in five
Latin American countries
Int. J. Environ. Res. Public Health 2024, 21, 134 7 of 19

Table 3. Cont.

Reference Populations Intervention Country Method/Outcomes Timeframe Setting

A qualitative research
Exploration of relationships,
methodology of semi-structured
Managers and clinicians behaviours, and perceptions The National Health
in-depth interviews applied to a
NG [47] of the NHS in the between managers and United Kingdom --- Service in the
sample of 4 hospital consultants,
United Kingdom clinicians regarding value-based United Kingdom
4 senior managers, and
healthcare
4 board executives
Qualitative study through
Exploration of the ways in
Representatives of Dutch semi-structured interviews and
which Dutch hospitals were Hospital organisations in
Steinman et al. [48] hospitals The Netherlands focus groups with ---
implementing and pursuing the Netherlands
(the Netherlands) representatives of
value-based redesign
Dutch hospitals
Professionals and Pilot study for the
Members of the Value-based healthcare project implementation of VBHC, in
Hospital Universitario
Verela-Rodríguez et al. [49] Population attending the implementation in a hierarchical Spain which qualitative techniques 4 years
12 de Octubre Madrid
Hospital Universitario tertiary hospital such as focus groups and the
12 de Octubre Delphi technique were included
Qualitative research using the
Delphi technique with a group
A Dutch expert panel The generating of a consensus of 9 Dutch experts on actions
The healthcare system in
Steinman et al. [50] about VBHC consisting on key actions and practices for The Netherlands and practices that would ---
the Netherlands
of nine members VBHC implementation contribute to implementing
VBHC in the Dutch
healthcare system
Exploration of stakeholders’
perspectives on the relevance Mixed methodology through
Members of Germany’s and feasibility of actions and interviews and questionnaires The healthcare system in
Krebs et al. [51] Germany 2 years
healthcare system practices related to the (using the Delphi method) with Germany
implementation of VBHC in the health experts
German healthcare system.
Int. J. Environ. Res. Public Health 2024, 21, 134 8 of 19

Table 4. List of studies included for the scoping review.

Reference Methods VBHC Definition Key Elements of Implementing VBHC Outcomes of VBHC Implementation
- Patients appreciated the value-focused
care they received; practitioners were
more aware of what creates value for pa-
- Organising healthcare around inte- tients; increased co-operation between de-
Value is defined as health outcomes grated care units; involving patients partments and the professionals working
achieved per “dollar” spent. or patient representatives; the iden- in them.
VBHC implies creating value for tification of outcome measures that - Increased awareness about the necessity
Nilsson et al. [41] Qualitative patients; basing the organisation of create value for patients; the acces- of cooperation between inpatient and out-
medical practice on medical conditions sibility of data—up-to-date IT sys- patient care; increased accessibility to pa-
and care cycles; and measuring medical tems; time; the presence of leader- tients by receiving care at the appropriate
outcomes and costs. ship; measuring the costs of the en- level; improvements in outcome measure-
tire care process. ment, patient follow-up, and the under-
standing of different conditions in each de-
partment and different patient subgroups.

- Better quality of care; increased staff

- The presence of leadership; the iden- job satisfaction.
Patient value refers to the quality of tification of outcome measures that - Improved communication between in-
Nilsson et al. [42] Qualitative create value for patients; the acces-
care and treatment provided. patient and outpatient care; improve-
sibility of data—up-to-date IT sys- ments in outcome measurement and pa-
tems; involving patients. tient monitoring.
Value is defined as health outcomes
achieved per ‘dollar’ spent.
VBHC implies creating value for - The presence of leadership; time; - It enhanced the importance of including
Nilsson et al. [43] Qualitative patients; basing the organisation of planning and preparation in the pre- the patients’ perspective and what is im-
medical practice on medical conditions implementation phase. portant to them.
and care cycles; and measuring medical
outcomes and costs.
- Organising healthcare around in-
VBHC means improving outcomes for tegrated care units; the accessibil-
patients in relation to the costs of care ity of data—up-to-date IT systems;
Cossio Gil et al. [32] Qualitative while reducing the burden on the identification of outcome mea- ---
professionals and improving their sures that create value for patients;
job satisfaction. involving patients; the presence
of leadership.
Int. J. Environ. Res. Public Health 2024, 21, 134 9 of 19

Table 4. Cont.

Reference Methods VBHC Definition Key Elements of Implementing VBHC Outcomes of VBHC Implementation
- Organising healthcare around
integrated care units; the pres-
ence of leadership; accessibility
VBHC is defined as the best outcomes - Increased knowledge of best
of data—up-to-date IT systems;
Daniels et al. [44] Qualitative for the patient divided by the costs of VBHC practices.
time; organisational readiness in the
achieving those outcomes. - Increased efficiency in hospital systems.
pre-implementation phase; involv-
ing professionals from outside the
VBHC team.
- Organising healthcare around inte-
grated care units; the presence of - Improvement in the process of care by en-
leadership; involving patients or pa- suring the inclusion of patients’ wishes
VBHC is defined as the improvement of
tient representatives; organisational and needs; the use of systematic measures
Heijster et al. [45] Qualitative patient outcomes in relation to the
readiness in the pre-implementation to assess patient outcomes reduced inter-
optimal use of resources.
phase; multidisciplinary VBHC im- pretation bias, ensured consistent record-
plementation teams; the hiring of ex- ing, and avoided missing data.
ternal consultants.
Quantitative Value is defined as the ratio of health - Organising healthcare around inte-
Makdisse et al. [46] ---
and qualitative outcomes to costs for each patient. grated care units.
- Organising healthcare around in-
tegrated care units; organisational
Value requires improved results per readiness in the pre-implementation
NG [47] Qualitative - Increased efficiency in hospital systems.
unit cost. phase; the presence of leadership;
the accessibility of data—up-to-date
IT systems.
- Organising healthcare around inte-
- Improved communication between the
At VBHC, value is what matters most grated care units.
different care units involved in the com-
to patients. - The presence of leadership; Multi-
plete care cycle of a disease; improved ef-
Value is defined as the health status of disciplinary VBHC implementation
Steinman et al. [48] Qualitative ficiency of hospital services.
the patient (outcomes) divided by the teams; the identification of outcome
- Improved collaboration between team
resources required to achieve that measures that create value for pa-
members by creating a sense of shared re-
status (costs). tients; measuring the costs of the en-
sponsibility for certain objectives.
tire care process.
Int. J. Environ. Res. Public Health 2024, 21, 134 10 of 19

Table 4. Cont.

Reference Methods VBHC Definition Key Elements of Implementing VBHC Outcomes of VBHC Implementation
- Organising healthcare around in-
tegrated care units; the presence
VBHC is defined as an international of leadership; the accessibility of
trend that involves significant changes data—up-to-date IT systems; in- - Reduction in interpretation bias and
Verela-Rodríguez et al. [49] Qualitative at various levels of healthcare volving patients or patient repre- improvement of data quality (thanks
institutions, from management to the sentatives; the identification of out- to PROMs).
doctor–patient relationship. come measures that create value
for patients; measuring the costs of
the entire care process.
- Organising healthcare around inte-
Value is defined as patient health status grated care units; involving patients
Steinman et al. [50] Qualitative (outcomes) divided by the resources or patient representatives; the iden- ---
needed to achieve it (costs). tification of outcome measures that
create value for patients.
- Involving patients or patient represen-
Quantitative tatives; the accessibility of data; up-
Krebs et al. [51] ---
and qualitative to-date IT systems; multidisciplinary
VBHC implementation teams.
Note: Several studies that were examined did not provide information on certain aspects being reviewed, which explains the absence of data in specific table cells.
Int. J. Environ. Res. Public Health 2024, 21, 134 11 of 19

3.2. Results and Analysis

3.2.1. Definitions of Value-Based Care
The first specific objective was to identify and compare the definitions of value-based
care extracted from the scoping literature review. All the definitions found in the reviewed
literature placed the patient at the centre of the definition of VBHC. Nilsson et al. [41,42]
described VBHC as an approach based on three principles: first, creating as much value
as possible for the patient; second, basing the organisation of healthcare on the patients’
medical conditions and full care cycles; and third, the measurement of medical outcomes
and costs.
Aligned with the first principle highlighted by Nilsson et al. [41,43]; Steinman et al. [48,50]
stated that ‘value consists of what matters most to patients’, while Daniels et al. [44]
emphasised that patient value is defined as ‘the best possible patient-relevant health
outcomes and patient experience divided by the costs to achieve those outcomes’. In this
line of thought, Heijster et al. [45] explained that a key element of VBHC is ‘to improve
outcomes in daily practice that matter to patients while optimizing resource utilization’.
The optimisation of resource utilisation has been also mentioned in the definitions
found in Cossio Gil et al. [32]; Makdisse et al. [46]; Ng, S. [47], and Steinman et al. [48]; in
these, it was mentioned that, within a VBHC approach, improving value requires improving
outcomes per unit of cost. Thus, the importance of measuring both health outcomes and
costs, as supported by Nilsson et al. [41–43] in their third principle of VBHC, is highlighted.
This idea was also supported by the definition extracted from a study by Makdisse et al. [46],
according to which ‘the value equation is where value is defined as health outcomes relative
to the cost’.
Furthermore, for Cossio Gil et al. [32], VBHC must put patient outcomes at the centre
of the healthcare process. This idea is in line with the second principle of VBHC from
Nilsson et al. [39,41], regarding basing the organisation of healthcare on the patients’
medical conditions. This has also been supported by the work of Makdisse et al. [46], who
recommended a value agenda in which healthcare should be organised into integrated
practice units. This authors, as part of this value agenda, also mentioned that healthcare
systems should move to bundled payments for care cycles and that information technology
platforms must be enabled in order to achieve VBHC.
Cossio Gil et al. [32] also stated the importance of VBHC for professionals, as it can
be a key aspect for reducing the burden on professionals and improving satisfaction with
their work.
Finally, Verela-Rodríguez et al. [49] described VBHC as ‘an international trend that
implies significant changes at several levels of the healthcare institutions from managerial
viewpoints to the doctor–patient relationship’.
The analysis of all the selected studies confirms the presence of commonalities among
the identified definitions. For instance, the term ‘patient’ is consistently present in all
definitions, and the correlation between outcomes and costs is observed in 72.7% of the
studies. Yet, the distinctions among the definitions emerge in terms of how they articulate
the correlation between costs and outcomes. This connection is occasionally directly associ-
ated with the VBHC concept, while in other cases, it is associated solely with the definition
of ‘value’ as a constituent within the concept. Additionally, references to supplementary
factors beyond patient outcomes and costs, like the impact on professionals’ workload and
their job contentment, underscore the presence of a gap in comprehending the concept.

3.2.2. Key Elements of Implementing and Delivering Value-Based Care

The second specific objective of this present scoping literature review was to
identify the key elements of implementing and delivering value-based care into the
healthcare context.
Among the reviewed studies, the following key elements have been identified: lead-
ership, involving the patients’ perspective, organising the delivery of care in integrated
Int. J. Environ. Res. Public Health 2024, 21, 134 12 of 19

care units, the standardisation of outcome measures and accessibility of data, and having
enough resources in terms of time and human capital.
A total of nine studies considered the presence of leadership as a key element to
support and guide the (multidisciplinary) teams implementing the VBHC approach within
the hospital: Nilsson et al. [41,43]; Hejister et al. [45]; Daniels et al. [44]; Cossio et al. [32];
NG [47]; Steinman et al. [48] and Varela et al. [49]. According to Nilsson et al. [41,43],
effective leadership occupies a role within the team that is persevering, committed through-
out the process, able to motivate and drive the team, and is constantly able to bring new
ideas and approaches. This effective leadership was considered essential to ensure that the
implementation does not slow down or even that the value-based work does not come to
an end.
Hejister et al. [45]; Daniels et al. [44], and Cossio et al. [32] highlighted that effective
leadership is based on ensuring the involvement of patients and/or patient representatives,
as well as the necessary financial resources for the successful implementation of VBHC.
Likewise, Hejister et al. [45] highlights the figure of the clinical leader, and Daniels et al. [44]
highlights the figure of the medical leader as figures responsible for leadership in order to
successfully launch the implementation of the model. While for NG [47], in the frame of
VBHC, great leaders are those that support the implementation of changes and reforms to
ensure organisational efficiency with clear pathways for patients [47].
On the one hand, several of these studies focused on the importance of leadership in
structuring the work among the team in the pre-implementation phases of VBHC [43,48]. In
this sense, studies confirm that leadership by the hospital director, according to which the
VBHC approach should be used as a management tool, allows for the legitimacy of decisions
within the teams and is conceived as crucial for the prior organisational redesign necessary
for the subsequent successful implementation of VBHC [43,48]. On the other hand, another
study highlighted the relevance of leadership in both the pre-implementation phase and
also in the leading of the implementation process to ensure the motivation of the team
during the first months [41]. Although, without providing details, other studies also allude
to leadership and coordination as a key step in ensuring the successful implementation of
VBHC [49].
Studies also agree on the importance of involving the patients’ perspective, although
they differ in their manner. Some of the studies emphasised that the patient is at the core or
centre of VBHC [43,47,51]. In the same line, other studies highlighted the importance of
involving patients or patient representatives during the implementation process [41,45].
According to Nilsson et al. [41], patient involvement is key to understanding the patients’
point of view and to ensure that there are no discrepancies between patients’ experiences
of value and how teams implement VBHC. In this sense, involving patients or patient
representatives allows teams to seriously evaluate care delivery in relation to patient
value [41]. In the same vein, other studies highlight that patients as well as teams need to
have access to data in order to discuss changes in the care process together [32]. Finally,
other studies confirmed that VBHC contributed to highlighting the importance of including
the patients’ perspective and what is important to them [43].
Other studies emphasised that patients’ involvement alongside the multidisciplinary
team needs to be present not only at the implementation phase but also during the pre-
implementation design process. In this sense, patients are considered members of the
value team, and their participation is essential to ensure personalised care in which their
wishes and needs are included, and the outcomes that will be relevant to measure in later
stages are selected [45]. Other studies considered the patient perspective to be essential
when implementing VBHC, because patients’ perspective is key to developing tools that
are relevant to actually assess patient-reported outcomes (PROMs) and patient experience
(PREMs) through systematic measurements [32,49].
Other studies also mentioned involving patients in the shared decision-making process
as one of the most important elements of VBHC [32,50,51].
Int. J. Environ. Res. Public Health 2024, 21, 134 13 of 19

Another key element for VBHC is embedded according to the studies in the pre-
implementation phase, known by some studies as organisational [48], or more generically,
they refer to the organisational structure of hospitals [45,47].
In this respect, the studies emphasised that, prior to the implementation of VBHC, it is
essential to modify the healthcare organisation, which is usually organised in separate de-
partments, into integrated care units [32,41,44,49,50]. According to these studies, healthcare
systems that are organised in specialised departments make it difficult to assess outcomes,
to measure costs along the whole process, and to follow patients during the course of the
disease as they move from one department to another. For these reasons, it is considered
necessary to organise care delivery in integrated care units or in multidisciplinary care
pathways around a specific patient group with a specific medical condition [32,40,48–50] or,
in other words, towards a disease-oriented organisation that allows the entire care process
to be evaluated in terms of costs and clinical outcomes [48].
Standardisation of outcome measures and accessibility of data: Importance of ICTs.
As previously said, patients’ involvement is essential to know what value for patients
is. Thus, the identification of outcome measures relevant to patient groups, which creates
value for patients, is another key element in the implementation of VBHC [32,41,47–49].
Alongside the identification of outcome measures, the studies highlight the importance of
new technologies for recording and accessing outcomes which facilitates the implementa-
tion of VBHC. Several examples that confirm that IT support is an important factor for a
successful delivery of VBHC are presented in the reviewed literature. These include the
following: the creation of information platforms that enable communication and inform
both clinical teams about PROMs and patients about their health status [32], the devel-
opment of a coding system to measure outcomes across a whole group of patients [42],
the installation of supporting IT tools that allow for the searching of data in different IT
systems of a hospital [42,51] or that allow, in a given hospital, the systematic recording of
information from the primary source, the existence of an up-to-date IT system containing
the data, the opportunity to search for statistics for outcome measurement mapping [41], or
even the presence of national data registers [44].
Alongside the measurement of outcomes, several studies highlight the importance
of measuring the costs of the entire care cycle [40,48,49]. Along these lines, some studies
highlight that, in order to calculate the value for patients, it is necessary to measure the
costs per patient of the entire care process [49,50] or, in other words, to measure the costs of
the care cycles for each of the diseases they treat [48].
A few studies also highlighted the importance of having enough resources available
during the design and/or implementation of VBHC for the successful implementation of
this approach. In this regard, time was considered one of the most important resources in
many studies [41,43,44].
When planning VBHC implementation, time was found to be essential in order to
ensure the sufficient preparation of the teams to understand the meaning of VBHC and
what value-based work implies, to decide on the administrative resources needed for
the implementation process [43], to adjust the essential IT systems that would be key
during the implementation [41,43], and to detect, with the staff involved in the teams,
which results were interesting to measure the amount of time necessary to schedule the
required follow-up meetings to monitor the implementation process [50]. Once VBHC
was implemented, time was seen as a key resource to reflect and adapt to all changes
without losing track of the work being done [40,43,44]. Apart from time, human capital was
also found as a key resource for the successful implementation of VBHC. Several studies
highlighted the importance of having multidisciplinary teams for VBHC implementation
to ensure integrated and multidisciplinary value-based care [44,45,49,50]. Other studies
highlighted the hiring of external consultants as a key figure to structure the work in the
pre-implementation phase and to lead the implementation process in the first months,
supporting, guiding, and motivating the teams during the implementation process [41,45].
In other cases, it was also considered essential to involve professionals outside the VBHC
Int. J. Environ. Res. Public Health 2024, 21, 134 14 of 19

team, as it was felt that all professionals involved in the care of a given patient group
should support improvement initiatives [44].
Despite the recent implementation of this model, there is consistency across studies
regarding the critical elements necessary to guarantee its effectiveness in implementation.
In 75% of the studies, both the leadership and the organisation of integrated care units
emerge as prominent elements. Moreover, the significance of involving patients, ensuring
data accessibility, and updating IT systems is evident in over half of the studies. These
examples signify a substantial consensus among stakeholders regarding the essential
components aimed at enhancing care within a value-based care model.
Nevertheless, despite these commonalities, the differences among studies, even those
addressing identical elements, are striking. Certain studies mention leadership yet diverge
in attributing this role to various individuals, such as the hospital director, or remain
vague about who should possess this capacity. Moreover, there are differing perspectives
on its significance at different stages, with some emphasising its importance during the
pre-implementation organisational phase, while others highlight its relevance specifically
during the implementation of value-based care. Similar variability exists regarding the
inclusion of patients in these studies. While some emphasise considering the patients
directly, others discuss the potential inclusion of patient representatives. The discrepancies
in identifying crucial elements for the effective adoption of the value-based care model
imply a lack of uniformity in the understanding of its implementation. Consequently,
this variation in understanding could lead to differences in measurement and outcomes,
thereby complicating comparisons between implementations.

3.2.3. Resulting Outcomes of Implementing Value-Based Care

The third specific objective of this scoping literature review was to identify and sum-
marise the resulting outcomes, in terms of improvement in the quality of the care process,
of implementing VBHC, and how this may contribute to improving the efficiency and sus-
tainability of a healthcare system. Studies show positive results from the implementation
of VBHC, including improvements in the awareness of cooperation and actual cooperation
between the different departments involved in the patient care process and a better under-
standing of the different conditions in each department and different patient subgroups.
This improved coordination, together with VBHC, facilitated the achievement of outcome
measurements and improved the quality of data. In terms of patients, the implementation
of VBHC increased accessibility for patients to receive care at the appropriate level of care
and better patient follow-up. In general, VBHC implementation increased the sustainability
of organisations, in particular of those where professionals were committed, and strong
leadership was in place.
Different studies referred to certain human resources involved in VBHC implementa-
tion for their ability to guide positive outcomes [44,48]. In this sense, the studies highlighted
that involving professionals from outside the VBHC team (e.g., from other hospitals) who
care for a certain group of patients allows for the professionals to share the actions that are
being implemented with them and increase knowledge about the best practices [50]. The
specific presence of other professional profiles, such as managers, also was mentioned due
to their ability to foster communication between the different care units involved in the full
care cycle of a disease [48].
Generally, some studies highlight that working according to a standardised care plan
contributes not only to a greater awareness on the part of professionals to use hospital time
efficiently and a better structured care process but also to the higher job satisfaction of the
staff [42].
Other studies have highlighted that, in the implementation of VBHC, the commit-
ment and input of physicians and managers, together with clinical leadership, enabled
organisations to innovate and drive changes and reforms, achieving greater efficiency in
hospital services [44,47,48]. In this sense, some studies highlight that the most successful
and sustainable organisations have been those in which there was a greater degree of
Int. J. Environ. Res. Public Health 2024, 21, 134 15 of 19

commitment between doctors and managers [47]. Along the same lines, other studies have
highlighted physician leadership as a success factor due to the positive involvement of the
physician leader as an inspirational and motivating character with the ability to involve
others and assume responsibility [44], which led to a successful delivery of VBHC. Finally,
some studies highlight leadership within implementation teams as very beneficial for the
proper organisation of teams [48].
On the other hand, the studies highlighted that emphasising value for patients brings
benefits for the healthcare organisation implementing VBHC, as it enables (team) partic-
ipants to understand the patients’ point of view, become enthusiastic about the concept,
and strongly engage in implementation work [41].
Another important outcome of VBHC implementation was organisational improve-
ment in terms of increased cooperation between departments and between professionals
in these departments. In turn, this improved cooperation facilitated the achievement of
outcome measurements, patient follow-up, and the understanding of the different con-
ditions in each department and different patient subgroups [41]. In terms of improving
cooperation on a broader level, the implementation of VBHC also increased the awareness
of cooperation between inpatient and outpatient care, contributing to increased accessibility
for patients to receive care at the appropriate level of care [41,42].
The creation of integrated units around medical conditions also triggered positive
consequences by considering the fact that they could enable closer collaboration between
all those involved in the treatment of patients with a particular medical condition and allow
hospitals to better address the interdependencies of the different activities necessary for
patient care [43].
Finally, studies highlight that the implementation of VBHC improved data quality
by using systematic measures to actually assess patient-reported outcomes (PROMs) and
patient experience (PREMs) as well as enter the information into the system from the
primary source (physician/patient). This reduced interpretation bias, ensured systematic
recording, and avoided missing data [46,48]. More briefly, other studies conclude that
the use of patient-reported outcome measures has itself been a stimulating factor for the
implementation of VBHC [44]. Furthermore, the transparent display of health outcome
information, so that it is available to both care providers and the general public, has also
been shown to facilitate improvements in the health outcomes achieved [51]. In the same
vein, other studies confirm that having a coding system to measure health outcomes in
a subgroup of patients allows the team to critically examine processes and decisions in
relation to different treatment regimens [42]. More generally, other studies have emphasised
that value-based metrics have a driving effect on collaboration among team members by
creating a sense of shared accountability for certain goals [48].
In conclusion, the studies included in this scoping review present results (66.6%)
that refer to predominantly positive outcomes. These studies correlate these favourable
outcomes with the presence of key elements highlighted in the implementation of VBHC.
Nevertheless, a notable proportion of studies (33.4%) within this review do not present
specific outcomes or results. Furthermore, the disparities observed in the examined results
are due to the absence of a standardised foundation for the selection of key elements and
their implementation.

4. Discussion
This review describes the state of the art regarding the concept of VBHC, key elements
for its successful implementation, and the resulting positive outcomes of implementing
VBHC within a healthcare system.
In terms of the VBHC conceptualisation, the definitions found in this literature review
referred to both the general term VBHC and the meaning of value within the model.
Most of the studies agree on the definition of value and define it as the health outcomes
achieved for patients in relation to the costs of the whole process of care [27,35,52]. In this
sense, delivering value to the patient means improving health outcomes for the patient.
Int. J. Environ. Res. Public Health 2024, 21, 134 16 of 19

This definition of value is aligned with the definition of value of Michael Porter and
Elizabeth Teisberg in their 2006 book on redefining healthcare [26], with these authors in
this particular work being the pioneering authors of the VBHC approach.
Despite the unanimity in the definition of value, studies vary in their consideration of
the key elements or factors in the implementation of VBHC. This ambiguity in the concep-
tion of the term has resulted in multiple ways of implementing VBHC depending on the
geographical context and management of health systems [53]. This study may contribute
to unveiling this cloak of ambiguity about the key elements of VBHC implementation
presented in the scientific literature.
Thus, with regard to the key elements of VBHC, those most frequently examined
were, firstly, the existence of a leader with the capacity to motivate and guide the team in
the pre-implementation and implementation phase; secondly, the involvement of patient
perspectives to ensure that the implementation of VBHC is responsive to the patient
experience and to guarantee personalised care; thirdly, the creation of integrated care
units around specific patient groups or specific medical conditions that allow patients
to be followed throughout the process; fourthly, the identification and storing of patient
perspectives to ensure that the VBHC implementation responds to patient experiences
and guarantees personalised care; fifthly, the identification and standardisation of relevant
outcome measures for patients in conjunction with the development or improvement
of IT systems to ensure the recording, transparency, and accessibility of data by care
providers and patients; and finally, the provision of time and human resources to ensure
that implementation teams have the necessary time for preparation and the necessary
reforms prior to implementation and for monitoring and adapting to changes during the
implementation process. These elements have been identified in a wide variety of scientific
studies [45,49], and it is recognised that their combination is considered essential for VBHC
implementation. The pioneering work of Porter and Teisberg [26], as well as their further
research, has shown that the transformation from volume-based care to value-based care
must be based on a combination of six elements: organising around integrated care units,
measuring outcomes and costs per patient, bundled payments by care cycles, expanding
geographic reach, and enabling an informatics platform, with most of them being aligned
with the key elements of implementing VBHC found in this scoping review.
Regarding the identification of positive outcomes resulting from the VBHC im-
plementation, some benefits have been identified that could shed light for future
implementation actions.
Among them, some of the reviewed studies described improvements in cooperation
between professionals working in the healthcare system, both in terms of raising awareness
of the need of cooperation and improvements in actual cooperation between professionals
and departments involved in the patient care process. Cooperation has been shown to be
essential for optimal care provision in other studies [54,55]. In addition, it was described in
several of the reviewed studies [41,42] that the creation of integrated units was also seen as
beneficial in enabling closer collaboration between all those involved in the treatment of pa-
tients with a disease and between the different levels of care (inpatient and outpatient). This
improvement is supported by the ‘integrated care’ approach that seeks to better coordinate
care around people’s needs [56]. Along these lines, it was also found that the implementa-
tion of VBHC increased accessibility for patients to receive care at the appropriate level of
care and better follow-up. Other positive outcomes of the delivery of VBHC are that imple-
menting this model facilitated the achievement of outcome measurements and the quality
of the data collected. As widely highlighted by the ICHOM—International Consortium
for Health Outcomes Measurement—group, measuring outcomes is important to deliver
optimal healthcare that matters to patients. Thus, the improvement found in our literature
review in those terms are aligned with the ICHOM group’s vision, as they contribute to
value maximisation, where value is understood as ‘the best possible patient-relevant health
outcomes and patient experience divided by the costs to achieve those outcomes’ [44].
Previous studies confirm the high degree of the interpretive variability of the concept,
Int. J. Environ. Res. Public Health 2024, 21, 134 17 of 19

as well as the lack of consensus on its conceptualisation and the paucity of information
on the evaluation of the strategies implemented [57]. In this sense, the present scoping
review addresses the interpretative variability and differences in the conceptualisation of
VBHC, providing an individual and comparative analysis of the studies included, thus
adding value to previously published studies that agree on the existence of a gap around
a generalised definition and understanding of the model. In addition, this study sought
to address the paucity of results reported in previous studies on the evaluation of the
implementation strategies in place by providing a comprehensive analysis of the positive
results reported in these studies.
Despite the meaningful contributions of this literature review, this study is not without
its limitations. First, our study protocol was not prepared neither registered, as recom-
mended by the PRISMA 2020 guidelines. Moreover, our search was limited to studies
published in English and Spanish between 2013 and 2023, which may exclude studies pub-
lished in other languages that might be relevant to understand VBHC. In addition, most of
the studies included in this literature review are based on a qualitative methodology, which
may limit the extent to which the findings of this study can be generalised, and a number
of the reviewed studies simply narrate experiences without assessing the effectiveness of
implementing the system-wide intervention, which presents a major limitation, as there
are no data to guarantee that these interventions work. We believe that there is sufficient
consistency in the results analysed in this scoping literature review to be useful in guiding
future research, even though the identified limitations suggest the need for additional
research to address the gaps in our understanding of this critical healthcare paradigm, as
well as on the scalability and sustainability of the VBHC model.

5. Conclusions
In conclusion, based on the findings of this scoping literature review, the implemen-
tation of VBHC may contribute to an improvement in the efficiency and sustainability
of healthcare.
While most studies refer to some of Porter and Teisberg’s key elements, there is no
agreed generalisation of all of them, and there is interpretative variability that translates dif-
ferently in the way VBHC initiatives are implemented and the variety of positive outcomes
achieved in terms of effectiveness and the sustainability of healthcare.
These findings point to an urgent need for a common conceptualisation of VBHC,
focusing on key elements to reduce interpretive variability and to achieve a shared under-
standing of its application.

Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/ijerph21020134/s1, PRISMA-ScR checklist [36].
Author Contributions: Conceptualization, M.F.S. and T.A.B.; methodology, M.F.S. and T.A.B.; analy-
sis, M.F.S., T.A.B. and G.C.; manuscript writing, M.F.S. and T.A.B.; critical review, T.A.B. and J.G.F. All
authors have read and agreed to the published version of the manuscript.
Funding: This study has received funding from the FPU (Formación de Profesorado Universitario)
contract from the Spanish Ministry of Universities with the reference FPU19/04167 and from the
H2020 programme of the European Commission (ref. 875215).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: No new data were created or analysed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflicts of interest.
Int. J. Environ. Res. Public Health 2024, 21, 134 18 of 19

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