KEY SUCCESS IN THE TRANSFORMATION FROM VOLUME-BASED TO VALUE-BASED HEALTHCARE: A SCOPING REVIEW

This research aims to describe describe the factors that affect the shift from the conventional volume-based healthcare to value-based healthcare used a scoping review methodology. Data of research based on article search was conducted using online Scopus and Embase databases, resulting in 800 articles describing value-based healthcare. Duplication removal excluded 76 articles, screening excluded 295 articles, eligibility assessment excluded 76 articles, and the remaining 30 articles were included. The results of study show that VBHC was proposed as a shift in healthcare management entailing six reinforcing elements, but most hospitals have implemented only one VBHC element. The most common implemented elements are “the measurement of outcome and cost” and “the reorganization to integrated practice units.” The key success for the implementation of these elements are: (1) strong data collection to measure clinical outcomes that matter to patients, (2) clear governance of this data management, and (3) strong support from the high leadership to encourage multidisciplinary teamwork. Thus, the true VBHC system can only be reached when all the six elements are achieved. However, no single study describes a success in implementing all elements of VBHC. Hospital leaders need to be cautious when interpreting VBHC as not to think that the VBHC can be reached by cherry-picking only selected elements of VBHC. The palliative


INTRODUCTION METHOD
Since VBHC is an emerging topic and the previous studies are heterogenous, we conducted a scoping review to review the implementation of VBHC and the factors affecting it. We followed the Joanna Briggs Institute framework for population, concept and context, the framework of Arksey and O'Malley for scoping review methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Arksey & O'Malley, 2005;Peters et al., 2015;Tricco et al., 2018).

Identifying the research question
This research uses the population, concept and context (PCC) framework recommended by the Joanna Briggs Institute for Scoping Reviews (Peters et al., 2015). It aims to address the following research questions: a. Which element of VBHC is the most commonly implemented? b. What are the key success affecting the transformation to VBHC? Table 1 The PCC framework

Identifying relevant studies
Two databases were used: Scopus and Embase. The articles included were from 2006, the year when Porter first introduced VBHC, to 2022. The multiple keywords used were shown below. "value-based healthcare" OR "value based healthcare" OR "valuebased health care" OR "value based health care" OR "value-based care" OR "value based care" OR "vbhc" 2 Key success "key success*" 3 Hospital "hospital*" OR "healthcare" OR "health care" OR "health facilit*" To include relevant studies, we included English, full-text, empirical articles which described the implementation of VBHC to patients in a hospital setting and explicitly cited Porter's concept on VBHC. Articles describing other concepts of value-based healthcare were not included.

Study selection
The articles were exported to Mendeley, where duplicates were removed afterward. Two rounds of eligibility screening were conducted. During the first round, two reviewers screened for titles and abstracts independently. After every 200 articles, the two reviewers discussed, and when there were disagreements, the articles in question were raised to the third reviewer. During the second round, full-text screening was conducted independently by two reviewers.

Charting the data
The included full-text articles were imported and summarized using these extraction fields: author(s), year, title, country, VBHC element, affecting factors. The data were then regrouped to answer the research questions. Data in the field "VBHC element" were sorted to indicate which of the six elements of VBHC was most commonly implemented. Data in the field "affecting factors" were classified and used to describe the factors affecting a successful transformation to VBHC. We also emphasize the current lack ofdand thus the importance of collecting and reporting better cost data, as well as longterm and patient-centric outcomes. The ability to communicate value through a standardized framework is needed to facilitate shared decision-making among all stakeholders involved in value-based health care.

Figure 2. Distribution of articles by count
14 Kelly R. (1) a minimum amount of 90.000 euros was required to implement VBHC in medium to high complex medical conditions processes.
(2) In the process of data appropriateness and datarecording tools adaptation for outcome measures within the local system, 6 months were spent for the first medical condition to be considered. First, Korea must secure the commitment and support from healthcare providers by normalizing payment rates for healthcare providers. Second, more critical pathways must be developed and disseminated. Third, it is critical to start implementing performance-based risk-share programs. Fourth, more focus on registries and coverage with evidence development is critical, and last but not least, bundled payments with proven critical pathway care are some of the prerequisites to pressuretest the readiness of the healthcare system for establishing a full- Although the concept of six elements of VBHC has been around since 2006, the standard interpretation of how it should be implemented is still rarely described. Most hospitals implemented only one element of VBHC. Of the 30 articles included, most articles (24 articles) reported the implementation process of only one element of VBHC, 4 articles reported implementation of 2 elements of VBHC, and 2 articles reported implementation of 3 components.
The number of articles describing each element of VBHC is as follows: 9 articles implemented the reorganization to integrated practice units (IPU), 20 articles implemented the measurement of outcome and cost, 6 articles implemented the movement to bundled payments, 1 article implemented the integration of multi-site care delivery system, 1 article implemented the reach expansion across geography, and 1 article implemented enabling IT platform.
In reorganizing into IPU, the organizational readiness for change among healthcare professionals is crucial. The organization has to be able to provide and support teamwork environment that allows healthcare professionals from any specialty, with any typical work rhythm, to work with other healthcare professionals whose work rhythm are different. One article from the Netherlands described how the IPU was formed through a great effort from the steering committee chaired by the chief medical officer, who had determined the program-wide goals, monitored progress and selected new teams who wanted to start with VBHC. Another study mentioned that a set of Key Performance Indicators (KPI) for healthcare professionals need to be created to provide knowledge about all of the achievements/failures in health care. This way, the awareness of the importance of IPU can increase among the healthcare professionals (Annabathula et al., 2021;Cossio-Gil et al., 2022;Goretti et al., 2020;Heijsters et al., 2022;Nilsson et al., 2017;Nojszewska & Sielska, 2022;Varela-Rodríguez et al., 2021).
In measuring outcome and cost, it is of essence to measure the outcome that the patients prefer. Some studies still indicate that health professionals still seem to have a preferential right to interpret what is valuable for the patients. Patient-centred care has been studied for several decades but there is great variation when it comes to the effect on outcome measures. It is clearly essential to know how patients define value, otherwise the risk exists that care development will focus on what is easy to measure instead of what is most important and of greatest value to the patients. Some major factors affecting the implementation of measuring outcome and cost are (i) data infrastructure, (ii) a systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives, (iii) governance in which roles and responsibilities of physicians regarding outcome improvement are formalized, and (iv) implementation of outcomes within hospital strategy, policy documents, and the planning and control cycle (Ahmed et al., 2019;Allen et al., 2021;Amini et al., 2021;Bodar et al., 2020;Colldén & Hellström, 2018;Cossio-Gil et al., 2022;Goretti et al., 2020;Kuklinski et al., 2020;Lansdaal et al., 2022;Marotta et al., 2020;Nilsson et al., 2017;Ramos et al., 2021;Rutherford et al., 2021;Schraut et al., 2022;St John et al., 2021;Van Veghel et al., 2020;Varela-Rodríguez et al., 2021;Zipfel et al., 2019).
In moving to bundled payments, many current initiatives have been successfully centered on creating bundled payments for surgical care to reduce cost. The next challenge is to take these principles and apply them to nonoperative management of common chronic conditions. To optimize this, stringent risk stratification, development of evidence-based pathways, and dissemination of detailed outcome-based data must be implemented. In addition, hospital systems must evaluate risk allocation as repayment models are defined to avoid financially incentivizing doctors to select for only healthy patients with mild chronic conditions. Furthermore, moving to bundled payment may be complicated for practices that accommodate multiple payer types, as multiple eligibility requirements will have to be met and multiple provider-payer agreements will need to be forged (Heo et al., 2022;Hines et al., 2021;Hurh et al., 2017;Ryan et al., 2019;Stiegel et al., 2021).
In integrating multi-site care delivery system and expanding reach across the geography, the emphasis on cooperation with other institutes is significant, and this should ideally be characterized as a chain of care. This means that single services provided by separate institutes need to be strongly linked and that interorganisational and interdisciplinary service is essential for an intensive community-based care. The care chain includes care at both locations and the interaction between both hospitals (Van Veghel et al., 2020).
In building enabling IT platform, issues with Information and Communication Technologies (ICT), especially lack of integration with existing data systems, consistently impacted on successful program implementation. ICT issues led to decreased clinician (and sometimes patient) engagement, as potential benefits of PROMs were not considered substantive to justify the additional burden (e.g. time) placed on clinicians (and patients), particularly in fast-paced, business-oriented primary care settings who often see many patients in short periods. Furthermore, the IT platform should be able to provide a robust data warehouse where all the standardized outcome and cost data are integrated into the electronic medical record to give better visibility to healthcare professionals treating the patients and all other relevant stakeholders (Cossio-Gil et al., 2022).

DISCUSSIONS
Initially, Porter described the idea of VBHC to increase the value of health care delivery. This article reviewed the academic literature on the perceived concept of value elements from the hospital leaders perspective, and the key success when VBHC is implemented. The present study produces three main findings, which are discussed below.
First, no single study seems to truly succeed in implementing the concept how Porter has intended it . Our review identified differences in perceived concept of VBHC. Some authors conceptualized the overall concept of VBHC, some others only defined selected elements of VBHC. VBHC is interpreted differently across hospitals and heavily depends on the decisions from local hospital leaders.
Second, as a result of variable conceptualization of VBHC, this study found that hospitals do not approach all elements as integral parts of the VBHC. There are only two most commonly implemented elements: "measurement of outcome and cost" and "the reorganization to integrated practice units." These findings suggest that hospital leaders only pick selected element which best suits them, which in turn might cause fragmentation of the VBHC. When taken as a fragmented element, this could lead to a "false value." For example, pursuing cost reduction without regards to outcome will limit the ability to reach effective care.
Third, the outcome measures that Porter initially described stressed the importance of patient-centric measurement. This includes three tiers of patient outcomes: (a) the attained health status, (b) care-related outcomes, and (c) the sustainability of patient's health. Although