Value-Based Outsourcing Is Associated with Improved Healthcare Outcomes in Low- and Intermediate-Complexity European Hospitals: A Cross-Sectional Study from Spain

<b>Background:</b> Value-based healthcare (VBHC) has emerged as a promising approach for improving quality while reducing costs. While evidence from tertiary hospitals suggests that outsourcing to VBHC networks can improve safety, efficiency, and satisfaction, less is known about its impact in low- and intermediate-complexity hospitals. The Madrid Regional Health System (RMHS), which stratifies hospitals by complexity, provides a unique opportunity to compare performance across management models. The objective of this study was to compare outcomes between low and intermediate-complexity hospitals outsourced to a VBHC network with those operating under public management and outsourced to traditional for-profit organizations. <b>Methods:</b> The researchers conducted a cross-sectional analysis using the RMHS 2024 annual audit report. Sixteen low- and intermediate-complexity hospitals were included: three outsourced to the VBHC network Quirónsalud and thirteen under public management and outsourced to a traditional private for-profit network. Monographic and long-term facilities were excluded. Variables included case mix complexity, quality and safety indicators (inpatient complications, hospital-acquired infections, low-risk cesarean sections), efficiency metrics (average and case-mix-adjusted length of stay), and patient satisfaction measures (survey scores and patient transfers under the Free Choice of Care Mandate). Continuous variables were compared using Mann-Whitney U tests and categorical variables with Chi-square tests. <b>Results:</b> Study hospitals managed more complex patients (median case-mix 1.06 vs. 0.88, <i>p</i> = 0.007). Despite this, no differences were found in complication rates. Hospital-acquired infections (3.47% vs. 5.46%, <i>p</i> < 0.001) and low-risk cesarean sections (16.1% vs. 19.3%, <i>p</i> < 0.001) were significantly lower in VBHC hospitals. Efficiency was improved, with shorter average length of stay (4.26 vs. 5.03 days, <i>p</i> = 0.031) and all study hospitals demonstrating lower-than-expected case-mix-adjusted stay, unlike several controls. Patient satisfaction was higher (0.91 vs. 0.87, <i>p</i> = 0.007), as were recommendation scores (0.96 vs. 0.92, <i>p</i> = 0.003). Patient transfers favored outsourced hospitals, with more patients choosing them and fewer leaving compared with controls. <b>Conclusions:</b> Low- and intermediate-complexity hospitals managed by a value-based network in Madrid achieved superior performance across safety, efficiency, and satisfaction indicators, despite treating more complex patients. These findings extend evidence for VBHC outsourcing beyond tertiary hospitals, highlighting potential for improved system-wide performance where universal coverage and hospital stratification ensure comparability. VBHC outsourcing may represent a viable strategy to enhance patient outcomes and optimize resource use in regional healthcare systems.