Saudi Value Based Healthcare

This new Action Plan aims to disseminate and explain the Council of Health Insurance (CHI) vision and plans for Value-Based Health Care (VBHC) in the Kingdom of Saudi Arabia.

Most of the programs that are part of CHI’s 2020-2024 strategy contribute to the VBHC agenda. For example: the value-based payment initiatives; implementation of NPHIES and data standards; payer and provider benchmarking; and casemix and patient classification systems (DRGs in this case).

As part of this strategy, CHI has devised the following strategic objectives:

• Enable target population segments to be fully covered and protected;
• Operate as a reliable, lean, and learning regulator;
• Improve the sustainability and innovation of the sector;
• Catalyze the digital transformation of the sector; and
• Enable payers and providers to improve their services to beneficiaries with progressive policies.

Current State:

Currently, the CHI scheme for the private sector is very transactional, with large volumes of itemized and packaged claims submissions, adjudication, and payment for rendered services. Annually, CHI reports that there are around 80 million claims (with a value of almost SAR 25 billion), adjudicated through payments entirely based on a fee-for-service (FFS) model and with none or limited outcome or performance related payments.

As such, as a volume driven health system, consensus is that it is prone to higher risks of supplier-induced demand and increased levels of fraud, waste, and abuse. In addition, volumes of better care are not correlated with better outcomes and health, and these could also represent a waste to the system.

VBHC Vision

As part of its new vision and strategy, CHI plans a transformation journey from today’s volume driven scheme (with misaligned incentives), towards a value-based health system (with value at the center and aligned incentives), through three main strategic objective aims:

1. Designing healthcare around the beneficiary;

To this end, the CHI has created the National Patient Reported Outcome Measure (NPROM) strategy. CHI has taken the initiative to create a strategy to standardize the way they gather and improve the quality of the Patient Reported Measures (PRMs). PRMs (i.e., any report of the status of a patient’s health condition, health behavior, or experience with healthcare that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else) are a means of assessing and improving the quality of care, and aree now becoming a widely used tool in developed countries. These developments have led to distinguishing Patient Reported Outcome Measures (PROM) and Patient Reported Experience Measures (PREM).

2. Improving health outcomes for the beneficiaries

The goal of the project is to build the CHI Population Health Management (PHM) program in line with national requirements and best practices. To achieve that, the project includes two workstreams 1) Population Health Management Program, which will include developing a PHM guide; and 2) Population Health Data and Analytics, which will include defining KPIs to support performance measurement, build dynamic dashboards, as well as develop a PHM use cases.

• Primary Care:

CHI developed a list of primary care initiatives, including one to design and implement a pilot specifically for the classification framework initiative across six pilot sites. This entails developing a classification framework with criteria that specify the minimum requirements of a robust primary care service, and also includes defining a list of primary care measures to measure the quality of services and outcomes of primary care and to ensure continuous improvement and excellence.

The last part of the project will be to develop a scale up plan where CHI will outline a detailed plan with future recommendations for the scaling up of the classification system to additional sites across the Kingdom.

3. Developing innovative financing models – paying for quality

The Council plans to introduce a combination of different models of payments for healthcare services. While the plan is to shift from FFS to VBHC, it is not expected that FFS will be completely replaced, given that some services by their nature can only be paid based on a FFS model. Nevertheless, CHI is considering introducing performance-based modification of FFS where applicable and necessary (i.e. Pay for Performance models).

The CHI presented their roadmap on how they plan to introduce Value-Based payment models. The proposed approach will be implemented in four phases, where certain pre-requisites are required to progress to the next stage. All phases have prior dependencies on different pre-requisites and their delivery is conditional in achieving the final goal

Saudi Billing System

The first step that CHI has taken was to introduce a billing system known as Saudi Billing System (SBS) to standardize payments in the scheme. As a result, all CHI participants use the same set of codes.

AR-DRG System

The next step is to shift to a case payment model for admitted care services. As Saudi Arabia has subscribed to ICD-10 AM/AR-DRG system, it is expected that in Phase 2 and 3, CHI will introduce this system as a main reimbursement model for inpatient services. However, there are certain per-requisites to achieve this shift to case payment. Some of the main pre-requisites will be accurate clinical documentation and accurate and complete coding of inpatient episodes, estimation, or actual calculation of AR-DRG relative resource weights for services rendered under CHI scheme

Bundled payment services.

The CHI will define payment bundles for 7 select conditions/procedures and develop the pathway and design of the payment bundle based on market preparedness and cost analysis through claims data, and stakeholder consultations. Already shortlisted conditions/procedures under Value Based Payment Pilot Project include cataract surgery, diabetes, pregnancy and childbirth, bariatric surgery.

The project delivery is structured in four phases:

• Derive learnings from best practices;
• Claims data analysis;
• Define clinical pathways and outcome measures; and
• Develop payment bundle & implementation plan.

CHI VBHC ACTION PLAN

CHI has developed an action plan based on the commitments set out in its strategy:

1. CHI Action 1: Standardized Patient Reported Measure Program
2. CHI Action 2: Population Health Program
3. CHI action 3: Primary Care Program
4. CHI Action 4: Australian Refined Diagnosis Related Group (AR-DRG)
5. CHI Action 5: Market Reference Price Project (MRP)
6. CHI Action 6: Bundled Payments
7. CHI Action 7: Value Based Payment Program Pilot