Value Based Competition in Health Care. A critical reflection from an ethical point of view.
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Since the first decade of this century, it has become clear that health care expenditures have grown tremendously, while its performance is characterized by low, or at least variable quality, under- and overtreatment, too many preventable errors, and serious limits in (equal) access to health care. Michael Porter, a professor of business strategy at Harvard University in the United States, has claimed that there is only one escape from this worrysome situation: the introduction of value based competition in health care (VBCHC). Porter’s VBCHC theory is based on two fundamental elements. First, competition will, as in any other economic sector, encourage health care providers to deliver high quality care for the lowest possible price. Second, competition should be based on value, which Porter defines as: ‘outcomes relative to costs’. In his work, Porter focuses on explaining how VBCHC should be applied. He pays little or no attention to the justification of his theory, let alone to the question whether VBCHC is an ethically defensible theory. Such an ethical reflection on VBCHC can also not be found in the literature yet. Therefore, this thesis investigates whether VBCHC can be ethically defended and what principles are relevant in the search for possible alternatives. This thesis shows that ‘competition’ is only one possible mechanism in the distribution of public goods such as health care. Whereas Porter combines competition with choice and targets and performance management, there are good arguments to claim that health care would be better off with an intelligent focus on trust in the trustworthy and voice in combination with choice. Regarding the element of ‘value’ in VBCHC, this thesis shows that Porter holds a rather reductionist conception of value. Instead of standardizing outcome measures for patients with the same medical condition, Value Based Medicine (VBM) offers an alternative approach that takes patients’ personal values as a starting point. Besides, instead of valuing health care only instrumentally (in order to achieve better health), care ethics may help to acknowledge the intrinsic value of the caring relation. Combining these alternative approaches with the ethically defendible elements of Porter’s VBCHC will not only affect the mechanisms for distributing health care (more trust and voice instead of a single focus on targets and performance management and choice), but also the way we measure and improve its quality (by trying to reach the deeper layers of the value of care).