The value-based **transformation journey**
The value-based transformation journey
What is value-based healthcare, and why is it important?
According to Dr Reem Bunyan, Chief Executive – Center for Improving Value in Health, KSA Ministry of Health, Co-chair, G20 Health Working Group in Riyadh, health systems are facing several challenges worldwide.
People are getting older and facing more chronic issues, while the cost of care is also on the rise.
These factors present a challenge: if health systems continue to function unchanged, they will not be sustainable going forward.
The answer, in her view, is to focus on outcomes.
Global health systems are already embarking on such a change – examples shared include Australia, Canada, the Netherlands, Spain, Sweden, the UK and the US.
Leading providers worldwide are furthermore increasingly focused on value, partly through the Organisation for Economic Co-operation and Development (OECD) enabling International Consortium for Health Outcomes Measurement (ICHOM) standards.
At its core, Dr Bunyan explains, value-based healthcare is the "need for balance between outcomes that matter to patients relative to cost, resources and effort."
If health systems continue to function unchanged, they will not be sustainable going forward.
Dr Reem Bunyan
Different frameworks exist, with the Harvard Business School model being the most widely recognised. The World Economic Forum published papers building on the Harvard framework.
The Oxford University group, in contrast, established its own framework with the inclusion of additional dimensions. The EU customised this in respect of its own values – an approach that Saudi Arabia has also followed.
Father in Mecca assisted by son (pre-pandemic)
Value-based healthcare with Saudi characteristics
The journey to establish Saudi Arabia’s health transformation began in 2016, with the launch of the nation’s overarching Vision 2030 and, correspondingly, the National Transformation Program (NTP).
This transformation – the biggest ever undertaken by the nation in any sector, involving a large budget, many healthcare workers and a large number of healthcare facilities – set out to align all system players to achieve the following three goals (the ‘Triple Aim’ introduced by the Institute of Healthcare Improvement in 2008):
- Improve population health;
- Achieve better care, including quality, safety, experience and satisfaction; and
- Reduce the cost of healthcare per capita.
Dr Bunyan emphasises that defining “value” is extremely important.
Accordingly, the Center for Improving Value in Health - an independent organisation in Saudi Arabia - worked with national and global experts to generate a common understanding of value among all stakeholders across the Kingdom, including policymakers, clinicians and executives.
This exercise resulted in a policy perspective on the definition of value in the national context.
The policy perspective mentioned above took into account several value-based healthcare frameworks that have emerged in recent years – Harvard Business School, the World Economic Forum, and Oxford University – alongside unique national elements that included:
- The national Basic Law of Governance, with two articles addressing public health and healthcare;
- Saudi Arabia’s commitment to achieving Universal Health Coverage, as part of Vision 2030; and
- Saudi people are spiritual, connected, and close to family and immediate communities.
The Saudi model, Dr Bunyan explains, consists of a balance of outcomes that matter most versus resources allocated to the basic care cycle, with the individual at the core followed by the immediate community and lastly national population.
According to Dr Mohammed Ibrahim AlSaghier, CEO – Health Holding Company, a huge political will through Saudi Arabia's Vision 2030 will be one of the biggest enablers of value-based healthcare, and will set an example in the region.
Indeed, the most successful examples of value-based healthcare worldwide have government as a key enabler, adds Jwaher Moteb AlSaud, Chief Beneficiary Affairs Officer – MHAP-MOH in agreement.
While Dr Shabab Saad AlGhamdi, Secretary General – Council of Cooperative Health Insurance (CCHI) believes that anchoring value as a strategic pillar at the national level will help the entire health system to think along the same lines – regulators, providers, and payers – seeking to identify where to maximise value and how to do so sustainably.
Ultimately, value-based healthcare will help the entire system to grow, creating a “win-win” for all stakeholders.
AlSaud sees value-based healthcare as a “building block” of Saudi Arabia’s health system transformation, centred around the people served and ensuring that the services provided are valuable to the end-user.
The ultimate beneficiary of value-based healthcare will be the patient, agrees Dr AlGhamdi, who will enjoy better access, higher quality of care and satisfaction.
Accordingly, he reveals, the CCHI – whose vision is to be an international leader in achieving the best value in healthcare for the beneficiaries of cooperative health insurance – has embarked on a national survey to evaluate satisfaction and identify areas of improvement.
Marwan Abalawi, Senior Analytics Manager – Lean Business, says that value-based healthcare Is focused on the individual, and ensuring they are healthy and safe through providing care when needed, at high value and at low cost.
Underlining the importance of sustainability, Dr Mohammad Ibrahim Alsaghier, CEO – Health Holding Company says simply that value-based healthcare is keeping the individual healthy so that they heal rapidly when ill.
More patients will be helped by keeping costs low. The value to the system at large, he concludes, is in keeping the population healthy through preventative care.
While Dr Abdullah Khoja, Head of Public Health Department, Project Lead for the Population Health Management Strategy, and Advisor – KSA Vision 2030 Realization Office, Saudi Ministry of Health, explains that value-based healthcare is focused on taking care of the population.
He describes the move towards population health as systematic, requiring transformation, utilisation of the best available resources, health system intelligence and the reorganisation of services.
The value to the system at large is in keeping the population healthy through preventative care.
Dr Mohammad Ibrahim Alsaghier
According to Dr Bunyan, understanding what the value-based healthcare “movement” means will impact how each stakeholder plays their respective role in the healthcare system.
Providers will, for example, consider how advice is given to individuals while also understanding the big picture of the population at large, factoring this in their decision-making.
According to Dr AlGhamdi, all providers are currently paid the same, regardless of quality, and value-based care will encourage them to plan better and provide safer care.
To incentivise providers to deliver high-value care and hold them accountable, a new payment model must be introduced that is different from the traditional fee-for-service approach rewarding volume: bundled payments.
Medical Supporting Services Building. King Faisal Specialist Hospital and Research Centre, Riyadh
Within this approach, payments for the entire episode of care – pre-op, surgery, post-op, and any rehabilitation – are bundled as one.
Once the system matures, the next step will be to move from bundled payments to population-based payments.
Bundled payments, he explains, will enable integrated and efficient care across treatment pathways.
Once implemented, they will drive value across the healthcare ecosystem.
The patient sees improved outcomes and reduced complication and readmission rates; the provider and payer share risk; and regulators enhance the wellbeing of the population and curb expenditures.
Examples of people worldwide receiving the same care with better outcomes include Sweden, where a spine bundled payment resulted in a 28 per cent reduced length of stay and recuperation rate, and a 6 per cent reduced cost per patient (SVEUS).
In the US, the Comprehensive Care for Joint Replacement Model (CJR) saved taxpayers US$5577, or 20.8 per cent per joint replacement care episode for 3,942 patients (CMS).
Dr Alsaghier says there is a value to physicians through providing the best care and clinical effectiveness while maintaining affordability for the community. He adds that providers will need to be highly efficient and provide the best outcome, as there is a cost associated with complications.
According to Abalawi, providers “will be incentivised in having a new way of paying” towards the value of the patient.
King Fahad Medical City, Riyadh
AlSaud comments on the challenge of introducing value-based healthcare to the private health insurance market, saying that some of the elements required do not exist in the market, such as population health.
According to Dr AlGhamdi, payers and providers have a “love-hate relationship” but highlights that this tension is good as it improves returns.
The CCHI is now requiring all payers to adopt care management and population health outcomes. All international payers are doing this, he continues – "and it is for their best interest".
One of the insurance companies in the United States, he adds, paid the provider to make sure they visit primary care at least once a year. If they do not achieve 70 per cent of beneficiaries visiting at least once annually they will be penalised.
This is done by the insurance company as they realise that by directing beneficiaries to primary care, they will save a lot of money at the emergency door.
How digital is enabling
It is not possible to realise the value until digitalisation is achieved, Dr AlGhamdi continues. A framework that leverages value-based care to fuel population health management must-have technology at its core.
As such, reveals Abdullah Al Sharqi, Chief Technology & Transformation Officer – CCHI, the CCHI and National Health Information Centre (NHIC) in cooperation with the Ministry of Health is building a national platform for health information exchange services, nphies (the National Platform for Health Insurance and Exchange Services; nphies also means ‘precious’ in Arabic).
nphies is described as an ambitious programme involving a complex ecosystem of more than 25 government entities, 25 payers and 16,000 healthcare providers.
The platform will host insurance services by interconnecting with all health insurance stakeholders, providers, and payers. It will also provide a unified digital health record for patients in Saudi Arabia, aiming to reduce the cost and time of providing healthcare services.
Indeed, over 2022-2029, nphies could generate up to SR26 billion savings from claim costs and operational efficiency.
Abalawi agrees that technology initiatives need to be supported to achieve value-based healthcare, suggesting that technology will enable regulators, providers, and payers to “do their job.”
Payers will want to see data where they can see the right care is provided at a reasonable cost; regulators would want patients to be treated in the right way in accordance with standards; and providers will be in favour of providing new ways of care, such as home-based care.
Dr Valerie Kirchberger, Consultant to the Chief Medical Officer and Head of Value-Based Healthcare – Charité Hospital, Berlin, Germany, describes how Charité Hospital’s path to value-based healthcare is focused on putting patients at the centre and focusing on what is good for them, rather than on quantity and number of cases.
Charité wanted to capture patient-reported outcomes and decided to do so electronically rather than on paper (which has worked well for others) or through calling patients.
The provider looked at international best practices – such as the Electronic Patient-reported Outcomes (ePRO) example of Memorial Sloan Kettering and the work of Dr Bach, Director, Center for Health Policy & Outcomes – before partnering with a digital startup in Berlin to collect and visualise PRO data.
This data is used both on a group level and at the patient level, allowing the physician to visualise PRO, through a login separate from the electronic health record, for long-term quality of life and outcomes for a patient.
“Our doctors really like the visualisation,” Dr Kirchberger affirms.
“We need a paradigm shift from value to volume, and the rest will follow.”
Dr Valerie Kirchberger
Rather than continue with two portals, Charité’s vision for the future is to have PRO data fully integrated with the electronic health record of the patient so that it is easily accessible by the physician at a click of a button.
Dr Kirchberger caveats that while digital tools can help providers accelerate their journey to value-based healthcare, the bigger enabler will be to change how care – currently provided on a short-term basis – is incentivised.
Charité – Universitätsmedizin Berlin
Value-based healthcare results to date
Dr AlSaghier highlights the emergence of a movement, offering the example of the First Health Cluster in Eastern Province, in Dammam, reviewing its first five-year plan to move towards value-based healthcare – a moment he describes as a particularly important milestone in the transformation journey in the Kingdom.
He also reveals success in measuring outcomes for 600 patients with type 1 diabetes in Al Ahsa, noting a 30 per cent drop and 40 per cent compliance among children and patients.
The numbers are “encouraging” enough to warrant an expanded focus to include Al Qassim and other areas. He explains that this demonstrates that providers can transparently publish metrics for outcomes, and that this can facilitate payment based on those outcomes.
He provides details around a contract in dialysis, involving approximately 6000 patients in Saudi Arabia, and a new payer programme that will sign a contract with a clinic to measure clinical and financial outcomes.
First Health Cluster in Eastern Province, Dammam, Saudi Arabia
Value-based care is expected to transform supplier-created demand into patient-relevant demand, emphasising services that add value to patient care and minimising services that do not.
This shift from fee-for-service to a value-based care model has implications for the field of radiology because if imaging and image-guided intervention services do not add value, or if their value cannot be understood and appropriately measured, then the importance of radiology in a value-based care environment could be minimised.
Understanding the value of imaging
Dr Yoshimi Anzai, Professor of Radiology – University of Utah, U.S., gives an overview of the healthcare payment models in the US and the recent pressure toward the price transparency of ambulatory services, including radiology.
She further discusses how consumers (patients) balance price (cost) and quality of healthcare services.
Anzai explains, “Payment is based on volume. That needs to be changed to focus more on the value and outcomes for patients. There has been a continuous decrease in reimbursements for imaging. The rising cost of healthcare has led to double-digit growth in the insurance premium. Small employers have stopped offering health insurance or redesigned the plans with cost-sharing to employees.”
In the US, within the High Deductible Health Plan (HDHP), a patient must spend over US$5000 before getting any benefit from the insurance companies.
Also, there is a wide price variation for imaging studies. Therefore, in 2020, the CMS Price Transparency Rule highlighted that hospitals must disclose standard prices of 300 “shoppable” services. These are non-urgent services that include imaging or ambulatory surgery.
The value of imaging can be demonstrated through quality and service such as accurate and timely diagnosis, and high quality of imaging.
“For healthcare, it is not just about price or cost, but about ensuring superior quality and providing value,” she says.
“Also, radiology is one of the most mentally demanding physician specialities with workload likely contributing to burnout, and this is where Artificial Intelligence/Machine Learning can play a crucial role in assisting with day-to-day operations.”
Carlos Francisco Silva, MD, EDiR, Radiologist, Member – Management & Quality Section, Portuguese Society of Radiology and Nuclear Medicine (SPRMN), Sertubal, Portugal, discusses the concept of value in radiology. He says that value equals to outcomes divided by cost. The outcomes include quality, efficacy, and safety.
He further highlights that radiology faces the problem of 30 per cent of waste in imaging exams due to tests and procedures that are unnecessary.
Artificial Intelligence/Machine Learning can play a crucial role in assisting with day-to-day operations.
Dr Yoshimi Anzai, Professor of Radiology – University of Utah
Some of the frequent mistakes that can lead to this waste include forgetting to compare previous CT/MRI reports, missing information, a valid information request but about the wrong patient, and missing/erroneous lab data.
“Good IT support is crucial for radiologists to integrate the necessary software and clinical decision support tools, otherwise they will lose too much time,” he stresses.
Furthermore, according to Silva, even though physicians are aware of the problem they continue to order low-value tests and procedures.
Radiologists need to work as a team and align clinicians’ value and goals to achieve better patient outcomes.
Carlos Francisco Silva
He shares findings where the reasons for this included malpractice concerns (87 per cent), desire to reduce uncertainty (84 per cent), “just to be safe” (78 per cent), and desire to keep patients happy and on patient’s insistence (>70 per cent).
He adds: “While value-based care needs to be relationship-centric, radiologists need to work as a team, and align clinicians’ value and goals to achieve better patient outcomes.”
When asked about the future of radiology, Anzai concludes by saying that imaging provides valuable information to physicians and healthcare workers, therefore, imaging will get faster to obtain, and its efficiency will continue to improve.
Radiologists, working alone or as parts of collective departments, must understand the principles underpinning cost allocation and the value-chain concept, and must take value-based healthcare into account when planning, developing and delivering their services.
By embracing value-based healthcare principles, and striving to create value where possible, radiology can contribute greatly to moving from a volume-driven system to a value-driven one, where as many investigations or interventions as possible contribute positively to patient outcomes.
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