Patients, caregivers, providers, provider organizations such as hospitals and provincial government funders each have their perspectives on how and when healthcare should be delivered and have expectations for its quality, convenience and efficiency. These competing viewpoints on the value from healthcare have led many to wonder: what is the path for improving value from healthcare in provinces?

A number of approaches have been proposed for improving value from healthcare. A non-exhaustive list includes improving chronic care coordination by strengthening primary care (van Weel and Kidd 2018), increasing the use of effective treatment and reducing waste (Berwick and Hackbarth 2012), measuring outcomes most important to patients and their caregivers (Kuluski and Guilcher 2019; Wong et al. 2019), integrating health- and social care services (Mason et al. 2015) and adopting new methods of paying for health services (Mechanic et al. 2009; Petersen et al. 2019).

There is an open question of whether these strategies are equally important to improving value. Managers face complex choices regarding their strategic decisions, the sequence of approaches, their interdependencies or intensity of achievement. For instance, there is little evidence indicating whether paying for services differently should be provinces' most important objective and for which service providers, versus whether chronic care coordination should be prioritized above all others. In this vacuum of information, there is a dearth of concurrent cost and outcome data that inhibit comparisons of provinces' strategies for improving value.

Nonetheless, provincial governments are making strategic decisions regarding the relative importance of these approaches and allocating financial and human resources accordingly. Since provinces' priorities differ, each must see a different path to improving value from healthcare.

With provincial autonomy currently unencumbered by strategic federal leadership in healthcare – or targeted program funding – and a lack of clear insight into "what is best," it should not be unexpected that there is a widening gulf between provinces' initiatives, priorities and investments.

For example, Ontario's recent The People's Health Care Act (Government of Ontario, 2019), enabling Ontario Health Teams (OHTs), is moving gently toward community-based networks and models of care through incentives for slowing the growth of per capita risk-adjusted spending and may include physicians. In striking contrast, provinces such as British Columbia (Clinical & Systems Transformation) and Alberta (Connect Care) have invested mightily in standardized electronic health/medical records hoping for future pay-offs.

In This Issue

In this issue of Healthcare Papers, a number of articles highlight examples of delivery system innovations to improve value. Presenting local opportunities to inform their peers, the exemplars are chosen from among a number of provinces to represent different perspectives across Canada.

This is the third issue of a four-part series focused on improving value from healthcare in provinces. The first issue presented conceptualizations of value, whereas the second issue explored what sources and types of data would be needed to drive improvements in value. This issue's examples provide insights into the current activities within provinces enabling improvements in value.

The featured articles highlight disparate local strategies for improving value – from incentives to coordinating care to clinician engagement. Three articles draw from different regions of Ontario. Together, these articles highlight the breadth and pace of changes and challenges facing providers, provider organizations and Ontario's Ministry of Health, all of which are finding their way with new regulations and structures.

This issue gives voice to innovative work occurring across the country and provides ideas for readers to pursue, or avoid, in their local environments. Unsurprisingly, the articles share important themes: data linkage across healthcare sectors, improved collaborative between sectors, a renewed call for collection of standardized cost and outcome information and burgeoning support for some integration between health and social care programs.

Downey et al. (2020) present an Ontario example of new collaboratives taking shape across sectors of the delivery system. Motivated by winter flu surge and enabling funding, the article provides an examination of structure and processes that facilitated a region's healthcare sectors to collaborate to reduce hospitalization congestion. The authors conclude by reflecting on the challenges and opportunities presented to providers to support integrated care.

Mathies (2020) explores the evolution of a community and network of providers that has become an OHT in Muskoka, Ontario. Based on a rich history of local experience, the article describes how the Quadruple Aim (Sikka et al. 2015) is used as a framework to consider how hospital capacity, linked medical records and clinical governance might be viewed differently in a province- and community-based model of healthcare delivery.

In an article that emphasizes challenges to significant reforms taking shape in Ontario, Woods (2020) juxtaposes personal leadership experiences in the US with characteristics of Ontario's health ecosystem. Noting that Ontario's providers, and healthcare sectors, have conflicting financial incentives that have led to bottlenecks, coupled with a lack of experience with capitated funding models, Woods concludes that OHTs will face substantial challenges moving from silo-based models. The article concludes with listing policy, regulatory and accountability issues that need addressing to maximize the likelihood of OHTs achieving their aims – activities that other provinces with nascent primary care reforms are watching closely.

From an often overlooked perspective, Vanderheyden and Prada (2020) call attention to the struggles facing the medical technology industry trying to straddle funders' competing objectives of short-term cost control with longer-term outcomes. Through experiences in other countries, the authors assert that governments that transition from cost minimization to episode- or population-based funding models create tremendous uncertainties for healthcare device innovators. The authors state that leadership is needed from provinces to establish parameters to rigorously measure cost and outcome data, information that could form a basis for value-based or risk-sharing partnerships between government funders and the device industry.

Through a body of evidence that articulates that children and their families with complex health and social needs can be underserved by provinces, Zwicker (2020) proposes a renewed focus on children and their families to improve value from healthcare. Drawing attention to fragmented health- and social care programs, inconsistent access, out-of-pocket costs and lack of outcomes measurement, Zwicker asserts that significant gains in wellness are to be realized by children and their families by coordinating health- and social care, supportive policies or regulations that span the continuum of care and measuring costs and outcomes over the life course.

Lewanczuk et al. (2020) describe provinces' daily struggles to minimize costs and improve value from public spending on health. Alberta Health Services has developed a framework for expressing its interpretation of value in Alberta, applying the framework at provincial or regional (zone) levels to measure value. The authors note that future steps to improve value will bind health more closely with social care programs, such as transportation, housing and seniors' and children's programs.

Based on personal experiences in the Maritimes, a former health system leader analyzes the complex web of government decision-making, clinician leadership and modernizing delivery of health services (Vaughan 2020). Featuring physician perspectives, the article discusses causes of regional delivery system reform failures, spanning physician engagement as leaders of reform, barriers of clinical governance and competition between funders, managers and providers. The article concludes that a path to improving value from healthcare in provinces will link payment reform with quality and outcomes across the care continuum.

Through the presentation of local initiatives and experiences, this issue demonstrates that there is no singular approach to improving value. Although a range of strategies may be needed, there is a clear need for empirical and qualitative evidence of the efficacy of provinces' efforts to improve value from healthcare. The final issue of this series of value from healthcare will reflect on the future of value-based initiatives and project successes onto provincial programs.

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