For years, Value-Based Healthcare (VBHC) has been presented through a simple and powerful idea: organize care around the value delivered to the patient, meaning the outcomes that truly matter to the person in relation to the resources needed to achieve them.
The theory is clear. The problem starts when we try to apply it in the real-world functioning of hospitals, primary care centres, services, consultations, technical committees, information systems, and financing.
VBHC has not yet become mainstream in healthcare because it is much more demanding than it looks. It is not just a new metric, a set of patient-reported indicators (the well-known PROMs and PREMs), a multidisciplinary clinic, a dashboard, a price negotiation, or a modern way of talking about quality. It is all of these things at once. And that is precisely where the difficulty lies.
The first barrier is organizational.
Health systems are still structured by specialties, services, procedures, and episodes. The patient, by contrast, lives through a trajectory, a journey: diagnosis, treatment, follow-up, complications, rehabilitation, preferences, and expectations. VBHC requires care to be reorganized around that journey. That is why expressions such as IPU (Integrated Practice Units) or IVUs (Integrated Value Units) cannot remain buzzwords and need to be put into practice. They are not just “clinics” with several professionals; they are structures of shared responsibility for outcomes לאורך a clinical pathway.
The second barrier is data.
There is no mature VBHC without robust clinical data, PROMs, PREMs, process indicators, and cost data. Yet information remains scattered, incomplete, and often not very usable. A hospital may have millions of records and still be unable to answer fundamental questions: Did patients improve? Did they improve in what matters to them? Which therapies produced the best real outcomes? How much did each journey cost? Without this capacity, VBHC remains trapped in discourse.
The third barrier is financial.
Payment systems remain, to a large extent, oriented toward volume, production, and isolated episodes. We say we want value, but we pay for activity. We say we want integration, but we fund separate procedures. We say we want prevention, but we mostly reward the response to disease already established. As long as financing is not aligned with outcomes, change will always be partial. Here, the Ministry of Health has a very important role, but so do ADSE, insurers, and even the medical association. There is an urgent need to align the nomenclature of medical procedures with this perspective.
The fourth barrier is cultural.
VBHC introduces an uncomfortable idea: professionals and organizations must be accountable not only for what they do, but also for what they manage to improve. Measuring outcomes, comparing results, and discussing clinical variation can be perceived as a threat. But accountability should not be seen as a threat. It should be understood as professional maturity: caring well means knowing, and showing, whether what we do produces real benefit.
The fifth barrier is governance.
For VBHC to be effective, pharmacy and therapeutics committees, medical devices committees, procurement, quality, IT, clinical management, and cost accounting must speak the same language. A therapy, a device, or a service reorganization should not be assessed only by price or novelty, but by the added value it brings to the patient journey. This requires quality objectives, monitoring, risk-sharing agreements, and formal re-evaluation mechanisms.
Patient participation also remains insufficient.
VBHC cannot be done only for patients; it must be done with patients. Only they can fully assess dimensions such as pain, fatigue, autonomy, anxiety, trust, dignity, and impact on daily life. If these dimensions are not measured and used in decision-making, the system will continue to value what is easiest to count, not necessarily what matters most.
In the end, VBHC is not mainstream yet because it requires several pieces to change at once: internal organization, culture, data, financing, technology, patient participation, procurement, medicines and devices assessment, continuous improvement, and analytical accounting. It is not enough to create a pilot project or collect questionnaires. All these dimensions need to be connected through a common logic.
The challenge, therefore, is not to prove that VBHC makes sense. That is already clear to everyone. The challenge is to create the conditions for it to stop being a promise and become the normal way of providing care. In a system under pressure from ageing, chronic disease, expensive innovation, workforce shortages, and limited resources, managing health only through activity and budget is insufficient.
VBHC has not become mainstream because it is difficult. But precisely because it is difficult, we have to keep insisting. It offers a common grammar to connect quality, sustainability, humanization, digital transformation, clinical governance, and accountability to patients and society. It is not a panacea, but part of the solution to healthcare problems lies here. That is the ontology we need to work on.
