Value in primary care clinics: a service ecosystem perspective

Summary

• In this article, we propose that value is a multidimensional construct, highlighting the need for a multi‐actor service ecosystem perspective of value in primary care clinics.

• We argue that different actors in the service ecosystem — for example, patients, their family members and carers, medical practitioners, practice managers, nurses, allied health workers, receptionists and practice owners — may value different aspects of health service delivery more highly than others.

• We describe ways in which value is perceived among actors in primary care, and highlight the need for a greater focus on a broader view of value involving the various stakeholders to realise better outcomes.

High quality primary care is the foundation of a high‐functioning health care system and is critical for achieving health care’s Quadruple Aim (enhancing patient experience, improving population health, reducing costs, and improving the health care team experience). ¹ Although Australia’s health care system can be regarded as being among the best in the world, ² primary care clinics, which are the front door of the health system in Australia, ³ currently face significant pressures from technological advances, ⁴ increasing patient demands, resource constraints, workforce shortages (including general practitioners), ⁵ and increasing shareholder expectations. ⁶ The global coronavirus pandemic puts further strain on clinics, creating a turbulent time for service provision. ⁷ , ⁸ Despite continued calls for a greater focus on the Quadruple Aim, ⁹ much work remains to be done to operationalise the concept in practice. One way to refocus on the Quadruple Aim is through understanding value from a service ecosystem perspective.

There is growing recognition of the importance of a service ecosystem approach. ¹⁰ Service ecosystems are relatively self‐contained, self‐adjusting systems where actors integrate resources for mutual value creation through their activities and interactions. ¹¹ Taking a service ecosystem perspective requires understanding the different actors’ perspectives and seeing how value can be co‐created by actors within the ecosystem. ¹¹

Moving from a fee‐for‐service (volume orientation) model to more patient‐centred care ¹² , ¹³ (value orientation) is expected to facilitate greater value for all stakeholders in a health care ecosystem, ¹⁴ , ¹⁵ and provides a means for clinics to be sustainable in a turbulent environment. Further, a more patient‐centred approach appears well aligned with the Quadruple Aim. We define the Quadruple Aim as consistent with the established work of Bodenheimer and Sinsky, ⁹ which highlights that care of the patient requires care of the service provider(s), in addition to enhancing the patient experience, improving population health, and reducing costs. Despite continued calls for a focus on the Quadruple Aim, much remains to be done in operationalising the approach in Australia.

Fundamental to achieving the Quadruple Aim is to understand what value means to the various actors in the clinic service ecosystem. That is, what patients, patients’ family members/carers, medical practitioners (doctors), practice managers, nurses, allied health workers, receptionists and owners value; and how value can be co‐created through activities and interactions within the primary care clinic. ¹³

Value has been viewed in a number of ways in health care. These include a finance‐first focus, ¹⁶ a patient‐first focus, ¹⁷ or some element of balancing these two goals. The potential tension between care of the patient and running a financially viable clinic, in our view, underscores the criticality of taking a broader view and understanding the components of the Quadruple Aim. Key questions to resolve include:

• ▪How can reducing costs be balanced with care of the patient?
• ▪How can patient experience at the clinic level be enhanced while at the same time enhancing wellbeing of the providers?
• ▪How can population health at the overall system level be improved?

Traditionally, value has been defined using economic perspectives and based on neoclassical, dyadic, linear evaluations of costs and benefits, specifically health outcomes per dollars spent. ¹⁶ A seminal study ¹⁸ found five different styles of value creation among cancer patients linked to patient self‐reports of wellbeing, highlighting the importance of viewing value from the different actors’ perspectives. In line with the evolution of the patient‐centred medical home model, Rollow and Cucchiara ¹⁷ highlight the importance of taking into account the patient’s view of value in primary care. They define patient‐centred value as what patients want from care and what they or their payers will pay for. Specifically, they observe that different patients, depending on their journeys and health conditions, value five components in different ways: health‐related expertise and functioning; cure – experience and functioning; healing; pre‐conditions of health, such as support for food and housing; and the patient’s experience of care in terms of access, their relationship with their care providers, technical excellence and amenities.

Rollow and Cucchiara argue that value creation in primary care can be achieved through three tiers of activities. At the most fundamental level are activities related to the organisation’s mission and customer values, the clinic’s business model, the organisational structure, and information technology. Next are activities around direct care, including access, relationships between the patient and provider, evidence‐based diagnosis and treatment, and care planning. At the third level are coordination activities, including, for example, self‐management support, coordination with other providers, and integration.

Taking into account the patient’s view of value in primary care is a critical step in the right direction, rather than thinking that value is created by providers for patients (as in a finance‐first perspective). However, it is also essential to understand that value is co‐created with and by others in primary care clinics. A considerable body of literature now articulates value as a multidimensional construct, derived from definitions based on utility, function, emotional appeal, perceived benefits and costs, and acquisition factors. ¹⁸ A growing consensus informed by developments in service‐dominant logic, suggests that value is an active process where a range of multiple actors in the service ecosystem work together to co‐create benefits for themselves and others through the integration of resources. ¹³ , ¹⁹ Rather than being delivered by providers for patients, value is co‐created through multiparty interactions within service ecosystems, ¹⁸ that is, between patients, practitioners and other members of the health care networks within which they interact. At the micro level of the ecosystem, this is the primary care clinic. ¹¹ If health care is a science and an art, ²⁰ in keeping with this view, we argue that embracing a multi‐actor perspective requires exploring commonalities and differences in how different health care ecosystem actors understand value, and how these commonalities and differences influence the value that is co‐created as a result.

Currently, in the Australian primary care landscape, this is not yet well understood. Concerns have already been raised from the perspective of quality improvement and accountability in primary care over whether the discussion of value in the Australian primary health care context needs to be better addressed, and the role of the Primary Health Networks for driving this transformation. ²⁰ Several years on, the literature is relatively fragmented in terms of whether the goals of the Quadruple Aim have been achieved. Understanding value as perceived by the different actors is fundamental to the transformation process. As turbulent times continue, the key challenges for each primary care clinic are:

• ▪truly understanding the importance of co‐creating value;
• ▪recognising that all actors have responsibility for co‐creating value, not just with patients, but with all actors in the clinic’s service ecosystem;
• ▪understanding that the different actors will perceive value in different ways; and
• ▪promoting interaction among and between actor groups to enhance experiences for all — patients, clinic employees and owners.

Open access

Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australian University Librarians.

Competing interests

No relevant disclosures.

Provenance

Commissioned; externally peer reviewed.