Value Based Healthcare in Psoriasis

The healthcare sector is under tremendous financial pressure but an increase in healthcare spendings does not seem to equate to better health outcomes or quality of care. Therefore, a dramatic shift is required as the current system is not sustainable. Several solutions have been proposed of which the conceptual framework known as value-based healthcare (VBHC) is further explored in this study for psoriasis. Psoriasis is a chronic inflammatory skin disease with a high prevalence of 0.1% to 11%. It is associated with psoriatic arthritis and numerous other comorbidities such as hypertension, obesity and diabetes. Psoriasis also significantly impacts patients' quality of life. The cost associated with managing psoriasis and its comorbidities present a substantial economic burden.

VBHC is a widely known conceptual framework, proposed by Porter and Teisberg, aimed at tackling the ever rising healthcare costs and variation in quality of delivered care. The framework is formulated on the premise that the health care sector should strive to achieve greater value for its patients. Value is defined through an equation in which the achieved patient-relevant outcomes are divided by the costs needed to achieve these outcomes. Both measures of outcomes and costs are looked at for individual patients over the full cycle of care, from the initial consultation to their final consultation, including all other medical interventions for the treatment of the medical disease. Previously, for psoriasis, it was unknown which outcomes actually mattered to patients. Therefore, a value-based outcome set (VOS), consisting of outcomes that matter to psoriasis patients, was first developed. Time-driven activity-based costing (TD-ABC) is the proposed costing method to accurately measure costs within the VBHC framework. Furthermore, in keeping with the VBHC framework, having greater understanding and transparency of costs may help with moving the sector away from the current fee-for-service structure towards VBHC payment initiatives, for example bundled payments. Bundled payments represent a lump sum payment to hospitals for the reimbursement of an entire episode of care for a patient. The payment is allocated to all services and providers across the various care activities (inpatient, post-acute care etc.).

In VBHC, value is created by using integrated practice units (IPUs). An IPU is an organizational entity that connects multiple specialisms and functions around a medical condition, with a distinct organizational structure, with a coherent set of agreements/contracts, with the aim to maximize value, by delivering maximum (or "the best possible") healthcare outcome for patients against minimum possible costs. It includes the full range of medical expertise, technical skills and specialized facilities needed, whilst putting patient experience central, as well as the management and coordination of the IPU and its interfaces. An IPU represents a fundamental part of the implementation of VBHC. The investigators have set up an IPU in psoriasis called PsoPlus, referring to the added value they believe their approach brings to psoriasis management.

The objective of this study is to investigate the impact of using the VBHC framework for the management of psoriasis. The IRIS (value In psoRiasIS) study will be a prospective clinical trial in which new patients attending the PsoPlus will be followed up during a period of 1 year. Both the outcomes achieved and costs will be assessed during this year. Subsequently, the two will be connected by conducting a data envelopment analysis (DEA) which will result in a value score for each patient. Based on this score and the evolution of this score conclusions can be made about the characteristics of patients that appear to experience more value compared to the other patients and the evolution of this created value over time. Secondary outcomes are related to comorbidity control, individual outcomes and determining cost drivers. In addition, a bundled payment scheme should be determined as well as potential improvements in the treatment process. This project will serve as a pilot project for the Belgium healthcare system.

The VOS consists of 21 outcomes which are measured using 12 instruments, of which 8 are reported by the patient and 4 by the provider. The following outcomes are measured:

• Symptom control via Psoriasis Symptom Inventory (PSI)
• Confidence in care via Patient Benefit Index (PBI)
• Control of disease via Patient Benefit Index (PBI)
• Treatment efficacy via Treatment Satisfaction Questionnaire for Medication (TSQM)
• Treatment convenience via Treatment Satisfaction Questionnaire for Medication (TSQM)
• Complete clearance via Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA)
• Almost complete clearance via Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA)
• Communication with care professional via Shared Decision-Making Questionnaire 9 item (SDM-Q9)
• Daily activity via Dermatology Life Quality Index (DLQI)
• Emotional well-being via Dermatology Life Quality Index (DLQI)
• Intimate relationships via Dermatology Life Quality Index (DLQI)
• Social activity via Dermatology Life Quality Index (DLQI)
• Difficult location clearance via Yes/No question in the Belgian Treat-to-Target consensus (T2T)
• Treatment tolerability via Yes/No question in the Belgian Treat-to-Target consensus (T2T)
• Treatment sustainability via custom Yes/No question
• Time to clearance via custom Yes/No question
• Cost of care (patient) via custom Yes/No question
• Cost of care (societal) via custom Yes/No question
• Treatment safety via Common Terminology Criteria for Adverse Events (CTCAE) criteria
• Productivity via Work Productivity and Activity Impairment - Psoriasis (WPAI-PSO)
• Comorbidity control via screening