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VBHC initiatives have been on the rise, ever since Porter and Teisberg introduced the concept of Value-Based competition, in response to the increasing cost of healthcare in the United States and the failure of reforms to improve health outcomes and contain costs. In their seminal book titled Redefining Healthcare (2006), Porter and Teisberg introduce seven principles of Value-Base competition with value being the main objective, simply defined as “the quality of patient outcomes relative to the dollars expended”.
This concept of value-based competition was taken further and developed into value-based healthcare which according to New England Journal of Medicine (NEJM) “is a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes” . Under this health care delivery model, providers are “rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way”.
Most of the programs that are part of CHI 2020-2024 strategy contribute to the VBHC agenda. For instance, value-based payment, implementation of NPHIES and data standards have direct contribution to achieving VBHC.
Other initiatives such as payer and provider benchmarking, and classification will also contribute towards this agenda. 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. Strategic objective number three aims to transform CHI scheme into a more innovative and sustainable healthcare-financing scheme, applying four major commitments to achieve this:
Competency- and quality-based healthcare is critical to our health system. It aims to improve outcomes that matter to individuals by organizing care around patients, measuring results and costs. These outcomes are used to improve quality of life and enhance the patient experience.
A patient-centered approach and organizing care around the individual enables meaningful engagement, improved healthcare service design, and strengthens the health system.
Over the past years, the measurement of healthcare outcomes as reported by beneficiaries has been encouraged as a means to assess and enhance the quality of care. Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures
(PREMs) — which refer to direct reports from patients on their health status, health behaviors, or experiences with care, without interpretation by a clinician or any other person — have become widely used tools in developed countries.
This strategy strengthens the voice of the patient in healthcare and aims to enhance competency- and quality-based care in the Kingdom of Saudi Arabia. It builds on leading practices and lessons learned from across the globe. The strategy seeks to standardize practices, metrics, and systems to improve the ability to make care decisions based on patient outcomes, ultimately improving competency- and quality-based healthcare.
The initiative aims to establish a Beneficiary Health Management Program for the Council of Health Insurance's beneficiaries, in alignment with national requirements and international best practices.
As part of efforts to promote the concept of primary care, the Council of Health Insurance launched the Primary Care Program in the private sector. This program aims to review, design, and implement a pilot framework and classification standards for primary care centers across six pilot sites in the private sector.
The pilot Value-Based Payment (VBP) program aims to design and test VBP contracts for cataract surgeries in collaboration with a selected group of healthcare providers in the private sector in the Kingdom of Saudi Arabia
The Council of Health Insurance has outlined a transformation plan from the current volume-based model to a value-based care model focused on efficiency and quality, emphasizing outcomes, patient-centered care, and aligned incentives. As part of the Council’s new vision and strategy, the VBP program is being implemented as a new healthcare financing approach aimed at linking payment to value and outcomes rather than volume.
The objective of this project is to define bundled payment packages for seven (7) selected conditions/procedures and to develop the pathway and design for bundled payments based on sector readiness and cost analysis derived from claims data.
As part of the Council’s new vision and strategy to achieve higher quality and efficiency in healthcare, and within this context, the Council of Health Insurance is implementing the Value-Based Payment (VBP) program as a new methodology for healthcare financing, aiming to link payment to value and outcomes rather than volume.
The purpose of this project is to identify appropriate contracting tools to lead and sustain efficiency- and quality-based practices across insurance companies and healthcare providers.
The project is expected to produce contract templates for all stakeholders in the sector, including insurance companies, healthcare providers, medical device suppliers, and pharmaceutical companies.
The Diagnosis-Related Groups (DRG) system supports value-based healthcare by assigning value to the Saudi health insurance sector to enable better beneficiary management. The primary objective is to promote value-based care by achieving excellence in bundled cases, implementing the DRG system, enhancing transparency, enabling innovation, and improving sector efficiency through the following:
The Saudi Billing System (SBS) is a classification and coding system for all healthcare service bills in the Kingdom of Saudi Arabia. The Council of Health Insurance continuously works to operate and enhance the SBS, ensuring it serves as a legitimate enabler for all initiatives focused on efficiency, quality, and healthcare transformation programs.
Clinical Documentation Improvement (CDI) in the Saudi healthcare system is considered invaluable for both insurance companies and healthcare providers. Accurate and comprehensive patient documentation ensures better communication, improved clinical decision-making, and enhanced patient safety.
For insurance companies, comprehensive documentation supports accurate coding and billing, reducing the risk of claim denials and audits, while facilitating proper reimbursement for services rendered. Moreover, effective documentation enables better assessment of healthcare quality and outcomes, fostering stronger collaboration between insurers and providers and supporting value-based contracting arrangements.
For healthcare providers, robust clinical documentation not only ensures optimal reimbursement but also strengthens continuity of care, facilitates compliance with regulatory requirements, and enhances legal defensibility.
CHI VBHC whitepaper
AR-DRG whitepaper
CHI Population Health whitepaper
CHI VBHC action book
Population Health Management Guidebook
Patient Reported Outcome Measures Strategy (PROM)
Measuring the Voice of the Beneficiaries
The Importance of Patient-Centered Outcome Measures
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