Overview
The concept of value-based healthcare (VBHC) has gained considerable traction over the past two decades, yet its implementation remains fragmented and methodologically inconsistent. A new ISPOR Special Task Force report by Grueger et al. (2026) tackles this problem head-on by proposing a structured integration of Health Economics and Outcomes Research (HEOR) methods into VBHC design, implementation, and evaluation. The report, published in Value in Health, offers both a diagnostic assessment of where these two fields diverge and a prescriptive framework — the “IMPACT” checklist — for bringing them together.
Methodology
The task force employed a mixed-methods approach combining a targeted literature review of 109 studies, semi-structured interviews with 24 international experts, and a structured survey of a 9-member Expert Advisory Board (Grueger et al., 2026). The literature search covered PubMed and Google for articles published after 2000, drawing empirical subsets from two existing systematic reviews (Vijverberg et al., 2022; Leao et al., 2023). Three types of articles were reviewed: conceptual articles comparing VBHC and HEOR, white papers on VBHC implementation, and empirical articles reporting outcomes of multicomponent VBHC interventions.
Key Findings
One of the report’s most striking findings is that while approximately two-thirds of the empirical VBHC studies applied some form of HEOR method, the vast majority relied on simple cost analyses. Comprehensive economic evaluations — the kind that would allow robust value comparisons across conditions and settings — were rare (Grueger et al., 2026). This finding underscores a persistent methodological gap: VBHC initiatives are measuring outcomes and costs, but not systematically evaluating whether the value delivered justifies the resources consumed.
VBHC vs. HTA: Two Lenses on Value
The report draws a clear distinction between VBHC and Health Technology Assessment (HTA). VBHC places outcomes in the numerator, asking how much health improvement is achieved per unit of cost. HTA inverts this ratio, asking how much cost is incurred per unit of health gain. VBHC focuses on “outcomes that matter to patients” using a broad set of measures across entire care pathways. HTA aggregates health gains into a composite metric — typically quality-adjusted life-years (QALYs) — to facilitate resource allocation decisions (Grueger et al., 2026). Despite these differences, both approaches aim to improve health system performance, and HEOR serves as the methodological bridge between them.
Three Areas of HEOR Contribution to VBHC
The expert interviews revealed three key areas where HEOR can directly support VBHC implementation:
- Incentive design: HEOR’s experience with outcomes-based contracting and alternative payment models can inform the financial architectures needed to sustain VBHC initiatives. HEOR can also model the breakeven points where incentives should activate to remain sustainable for health system design (Grueger et al., 2026).
- Cost analysis and transparency: HEOR microcosting techniques can complement VBHC’s preferred method of Time-Driven Activity-Based Costing (TDABC) to provide more granular resource-use data across entire care cycles (de Silva Etges et al., 2022; Leusder et al., 2022). Clarity on the cost perspective — whether provider, payer, or societal — is essential for meaningful cross-site comparisons.
- Outcomes measurement: HEOR methods such as patient preference studies and Multi-Criteria Decision Analysis (MCDA) offer rigorous approaches to combining patient outcomes with cost considerations without necessarily collapsing everything into a single metric like the QALY (Grueger et al., 2026).
The IMPACT Framework
The most actionable output of the report is the “IMPACT” framework — a structured guide for incorporating HEOR methods into VBHC:
T — Transparency: Apply empiricism that is transparent, allowing stakeholders to provide input and calibrate systems for sustainable partnerships.
I — Incentives: Test and calibrate incentive structures for VBHC implementation, including alternative payment models and pay-for-performance schemes.
M — Modeling: Use biostatistical and economic evaluation modeling to simulate and test VBHC design efficiency prior to implementation.
P — Patient-centered: Incorporate mixed methods and comparative effectiveness research to verify that VBHC design benefits intended consumers.
A — Assessment methods: Apply data-driven empiricism to iteratively test VBHC performance and ensure systems reach their intended goals.
C — Costing: Ensure thorough costing that examines economic impact from multiple perspectives — provider, payer, and patient.
Importantly, IMPACT is not a reporting standard or evaluative scorecard. No single VBHC initiative is expected to deploy all methods listed; rather, practitioners should select the HEOR tools most relevant to their specific context (Grueger et al., 2026).
Defects in Value
The report introduces the concept of “defects in value” — avoidable sources of waste, harm, inequity, and inefficiency that erode system performance (Pronovost et al., 2021; Dietz et al., 2023). The task force argues that HEOR tools such as cost-effectiveness analysis, budget impact modeling, and return-on-investment frameworks can quantify these defects and evaluate strategies for their elimination. This framing reorients the VBHC conversation from aspirational outcome improvement toward systematic identification and removal of value-destroying processes.
Advisory Board Consensus
The Advisory Board survey demonstrated strong agreement: average recommendation scores ranged from 4.00 to 4.33 on a 5-point Likert scale, with 86% of responses falling in the “agree” or “strongly agree” categories (Grueger et al., 2026).
Critical Assessment: What the Report Leaves Unaddressed
While this ISPOR STF report makes a substantive contribution to aligning VBHC and HEOR, several gaps deserve attention.
1. Digital Health Infrastructure
The report is notably silent on digital health infrastructure. Successful VBHC implementation increasingly depends on interoperable electronic health records, real-time data analytics platforms, and AI-assisted decision support systems. The report acknowledges that IT-support platforms were among the least frequently reported VBHC components, but does not explore why this is the case or how digital maturity affects implementation success.
2. Low- and Middle-Income Country (LMIC) Perspective
The perspective on LMICs is largely absent. The expert interviews drew from Brazil, Belgium, Malaysia, and several European and North American countries, but the recommendations assume institutional capacities — standardized costing systems, PROMs infrastructure, outcome registries — that many health systems in developing economies lack. The specific challenges of implementing HEOR-integrated VBHC in systems with mixed financing, informal care pathways, and limited health informatics capacity are not discussed.
3. Workforce Readiness
The report does not adequately address workforce readiness. VBHC implementation requires clinicians, managers, and administrators who can interpret economic evaluations, design outcome measurement systems, and navigate bundled payment models. Without a parallel investment in health management education and training, even the best methodological frameworks risk remaining theoretical.
4. Readiness of Alternative Value Metrics
While the report highlights emerging alternatives to the QALY — such as Generalized Risk-Adjusted Cost-Effectiveness (GRACE; Lakdawalla & Phelps, 2021), Health Years in Total (HYT; Basu et al., 2020), Equal Value of Life Years Gained (evLYG), and MCDA (Padula & Kolchinsky, 2024) — it does not critically evaluate their readiness for routine application. These methods remain largely academic, and practical guidance on when and how to deploy them in real VBHC settings would have strengthened the recommendations.
5. Methodological Limitations
The report’s methodology, while pragmatic, carries inherent limitations. The literature review was targeted rather than systematic, and the expert sample was purposively selected. The authors acknowledge these constraints, but they do limit the generalizability of findings. A more structured approach — perhaps a Delphi consensus process with broader geographic representation — could have produced recommendations with greater external validity.
Conclusion
Despite these gaps, the Grueger et al. (2026) report represents an important step toward disciplinary convergence. For health management scholars and practitioners, it provides both a conceptual map and a practical toolkit for integrating economic rigor into patient-centered care delivery. The IMPACT framework, in particular, deserves attention as a starting point for institutions seeking to move beyond ad hoc VBHC experimentation toward evidence-informed, sustainable health system transformation.
References
Basu, A., Carlson, J., & Veenstra, D. (2020). Health years in total: a new health objective function for cost-effectiveness analysis. Value in Health, 23(1), 96-103.
Dietz, D. W., Padula, W. V., Zheng, H., Monson, J. R., & Pronovost, P. J. (2023). Improving value in surgery: opportunities in rectal cancer care. A surgical perspective. Annals of Surgery, 277(6), e1193-e1196.
da Silva Etges, A. P. B., Urman, R. D., Geubelle, A., Kaplan, R., & Polanczyk, C. A. (2022). Cost standard set program: moving forward to standardization of cost assessment based on clinical condition. Journal of comparative effectiveness research, 11(17), 1219-1223.
Grueger, J., Lainé, E., Goncalves, F. N.-R., Middelhoven, H., Padula, W. V., Etges, A. P., & Steuten, L. (2026). Applying health economics and outcomes research methods in value-based healthcare implementation: An ISPOR Special Task Force Report. Value in Health. Advance online publication. https://doi.org/10.1016/j.jval.2026.02.014
Lakdawalla, D. N., & Phelps, C. E. (2021). Health technology assessment with diminishing returns to health: The generalized risk-adjusted cost-effectiveness (GRACE) approach. Value in Health, 24(2), 244–249. https://doi.org/10.1016/j.jval.2020.10.003
Leao, D. L., Cremers, H. P., van Veghel, D., Pavlova, M., & Groot, W. (2023). The impact of value-based payment models for networks of care and transmural care: a systematic literature review. Applied health economics and health policy, 21(3), 441-466.
Leusder, M., Porte, P., Ahaus, K., & Van Elten, H. (2022). Cost measurement in value-based healthcare: a systematic review. BMJ open, 12(12), e066568.
Padula, W. V., & Kolchinsky, P. (2024). Can generalized cost-effectiveness analysis leverage meaningful use of novel value elements in pharmacoeconomics to inform Medicare drug price negotiation?. Value in Health, 27(8), 1100-1107.
Porter, M. E., & Teisberg, E. O. (2006). Redefining health care: Creating value-based competition on results. Harvard Business Review Press.
Pronovost, P. J., Urwin, J. W., Beck, E., Coran, J. J., Sundaramoorthy, A., Schario, M. E., … & Navathe, A. S. (2021). Making a dent in the trillion-dollar problem: toward zero defects. NEJM Catalyst Innovations in Care Delivery, 2(1).
Vijverberg, J. R., Daniels, K., Steinmann, G., Garvelink, M. M., Rouppe van der Voort, M. B., Biesma, D., … & van der Nat, P. (2022). Mapping the extent, range and nature of research activity on value-based healthcare in the 15 years following its introduction (2006–2021): a scoping review. BMJ open, 12(8), e064983.
Reviewed by Dr. Mehmet Nurullah Kurutkan | healthtopic.org