Pricing the national health insurance scheme in Qatar – opportunities and challenges

Abstract

Background In 2013, Qatar introduced a national health insurance scheme, called “Seha.” Stage 1 of the scheme covered women aged 12 years and older for health care and maternity services. Stage 2 was launched in 2014, and covered all Qatari nationals for a much broader set of services. In the future, Stages 3 and 4 will extend coverage to all non-Qatari residents within the country as well as visitors. The National Health Insurance Company (NHIC) manages Seha, with a Third-Party Administrator (TPA) contracted to manage provider claims. The Supreme Council of Health (SCH) acts as the scheme’s overall regulator, and is responsible for activities such as specifying coverage and approving pricing. A range of steps was taken to prepare for Seha’s launch. SCH mandated clinical coding using ICD-10AM, and hospitals recruited and/or trained clinical coders to use this system. The Australian Refined Diagnosis Related Groups (AR-DRGs) tool was adopted, and public sector hospitals embarked on the clinical costing of their services. In Stage 1, SCH decided to use a bundled payment method for health care services. AR-DRGs were chosen for pricing acute inpatient care, using 76 AR-DRGs relevant for women and maternity services. A modification of the Australian Tier 2 classification was adopted for specialist medical services, using 9 classes relevant to women’s health. In addition, a primary health classification was adopted based on 4 levels of complexity. Mammography and MRI were unbundled from the specialist and primary care service, but other imaging, laboratory, and pharmacy services were bundled into the price. Although this was not included in Stage 1, previous work had also recommended the adoption of Urgency Related Groups (URGs) classification for emergency care. Stage 1 was implemented with a limited network including both private and public hospitals. The launch of Seha involved providing information to prospective providers and conducting subsequent sessions to assist in operationalizing the price schedule and business rules. Seha’s challenges for Stage 2 included: pricing a much wider range of services than were included in Stage 1; expanding the scheme to a wider range of providers, including “stand alone” providers (i.e. those without the capacity to provide ancillary services); and addressing the limited availability of activity and cost information from the private sector.