Decision Instrument · Population Health Strategy · Payer or Provider
PHM Readiness Diagnostic
A 25-question structured assessment evaluating your Population Health Management readiness across cohort identification, clinical pathway integration, contracting capability, financial measurement, and governance architecture. Aligned with the CHI five-condition PHM strategy and the AR-DRG, NISS, and IA RBC reform environment.
5 domains
25 questions
Approximately 15 minutes
Payer or provider perspective
Self-assessment version. Available as a facilitated Full Diagnostic with NPHIES-data-grounded cohort identification analysis, contracting framework review, and a board-ready PHM capability roadmap.
Several questions have payer-specific and provider-specific variants reflecting different responsibilities in a population health management framework.
Section 1 of 50% complete
Section 1 of 5
Cohort Identification & Risk Stratification
Evaluates whether your organisation can identify, stratify, and segment the populations that PHM targets: not just at a single-condition level, but at the multimorbid patient level using NPHIES longitudinal data.
Has your organisation produced a quantified analysis of your beneficiary or patient population for the five CHI PHM target conditions: diabetes, hypertension, obesity, coronary heart disease, and smoking?
Strong - 3 pointsA comprehensive analysis exists with prevalence by condition, cohort overlap, and longitudinal trend tracking, updated at least annually.
Partial - 2 pointsSome conditions have been analysed but coverage is incomplete or analysis is not updated regularly.
Weak - 0 pointsNo structured analysis of the five CHI target conditions in your population.
Question 2
Has your organisation quantified multimorbidity patterns in your population: specifically the cohorts with two or more co-occurring NCDs, with cost and utilisation profiles by combination?
Strong - 3 pointsMultimorbidity is measured with cost-utilisation profiles by condition combination. Recognised that multimorbid patients are the primary unit of analysis.
Partial - 2 pointsMultimorbidity is acknowledged but not quantified or analysed by combination.
Weak - 0 pointsAnalysis is conducted at the single-condition level. Multimorbidity is not a recognised analytical category.
Question 3
Can your organisation generate risk-stratified cohort lists using NPHIES longitudinal data: identifying patients within a chronic condition cohort whose utilisation trajectory, comorbidity profile, or prescribing pattern indicates escalating risk over the next twelve to twenty-four months?
Strong - 3 pointsRisk stratification is operational, refreshed at defined intervals, and produces actionable cohort lists used by clinical and care management teams.
Partial - 2 pointsSome risk stratification has been attempted but is not systematic or routinely refreshed.
Weak - 0 pointsNo risk stratification capability. All patients within a diagnosis group are treated as undifferentiated.
Question 4
Have you produced a quantified projection of the actuarial impact of your chronic disease cohort over a 24-month horizon: linking cohort identification to expected admission rates, specialty drug utilisation, and total cost of care trajectory?
Have you produced a quantified analysis of your chronic disease patient panel: linking patient registry data to expected admission rates, readmission risk, and care plan adherence trajectories?
Strong - 3 pointsA formal 24-month projection model exists with documented assumptions, validated against historical data, and used in actuarial or clinical planning.
Partial - 2 pointsSome projection work has been done but not formally modelled or integrated into planning.
Are external population data sources integrated with NPHIES data to enrich cohort identification: laboratory results, biometric data, lifestyle indicators, or social determinants of health where available?
Strong - 3 pointsExternal data sources are systematically integrated and enrich cohort identification beyond what NPHIES claims data alone provides.
Partial - 2 pointsSome external data is accessed but integration is project-based rather than systematic.
Weak - 0 pointsCohort identification relies on NPHIES claims data only. No external enrichment.
Section 2 of 5
Clinical Pathway Integration
Tests whether identified PHM cohorts receive structured, documented clinical management with defined accountability and care coordination: distinguishing real PHM from member-engagement programmes that do not change clinical outcomes.
Tests against: Performative PHM · Engagement Without Intervention
Question 6
Are documented clinical pathways defined for the five CHI PHM target conditions: with sequencing of intervention, response measurement criteria, and escalation protocols for non-responders?
Strong - 3 pointsClinical pathways exist for all five conditions with documented intervention sequencing, response criteria, and escalation. Pathway adherence is monitored.
Partial - 2 pointsClinical guidelines are referenced but specific organisational pathways with response criteria are not documented for all conditions.
Weak - 0 pointsNo defined clinical pathways for the CHI PHM conditions.
Question 7
Is care coordination accountability formally defined between your insurer care management function and contracted network providers: with structured handoffs, clinical record sharing, and defined responsibility for which actor performs which role at each stage?
Is care coordination accountability formally defined within your organisation between primary care, specialty care, and ancillary services: with structured handoffs, integrated clinical records, and defined responsibility for which clinician owns which decision at each stage?
Strong - 3 pointsFormal care coordination protocols exist with documented accountability, electronic handoffs, and adherence tracking.
Partial - 2 pointsCare coordination occurs but is informal, with limited documentation of accountability or handoff protocols.
Weak - 0 pointsNo defined care coordination protocols. Patient management is fragmented across actors.
Question 8
Is there a structured care management programme for high-risk patients within the PHM cohorts: with defined enrolment criteria, clinical assessment protocols, intervention plans, and outcome tracking?
Strong - 3 pointsCare management is operational with documented enrolment criteria, defined protocols, and outcome measurement. Programme operates as a clinical discipline, not member outreach.
Partial - 2 pointsA care management programme exists but lacks structured protocols or outcome measurement.
Weak - 0 pointsCare management is essentially member engagement: reminder calls, basic education, without clinical intervention structure.
Question 9
Is medication management integrated into the PHM programme: with adherence monitoring, therapeutic substitution protocols, polypharmacy review, and prescriber feedback loops for the chronic disease populations?
Strong - 3 pointsPharmacy-PHM integration is operational with NPHIES refill data, adherence measurement, polypharmacy review, and structured prescriber feedback.
Partial - 2 pointsPharmacy is a separate function with limited integration into PHM clinical management.
Weak - 0 pointsNo medication management integration with PHM activities.
Question 10
Are PHM interventions stratified by intensity: with the lowest-risk cohorts receiving population-level interventions, moderate-risk receiving disease management, and highest-risk receiving intensive case management?
Strong - 3 pointsStratified intervention model is operational with defined intensity tiers, resource allocation by tier, and outcome measurement by tier.
Partial - 2 pointsStratification is recognised but interventions are not fully differentiated by intensity.
Weak - 0 pointsAll patients within a cohort receive the same intervention regardless of risk level.
Section 3 of 5
Contracting & Financial Architecture
Evaluates whether the contractual and financial infrastructure exists to align payer and provider incentives around population outcomes: rather than around episode volume.
Has your organisation deployed any outcome-based or population-based contracting arrangements with provider partners: with defined outcome measures, risk sharing structure, and adjustment mechanisms?
Has your organisation entered into any outcome-based or population-based contracting arrangements with payer partners: with defined outcome measures, risk sharing structure, and adjustment mechanisms?
Strong - 3 pointsOutcome-based contracts are operational for at least one chronic condition cohort with documented outcome measures and risk sharing mechanism.
Partial - 2 pointsOutcome-based contracting is being explored or piloted but not yet operational as a contract structure.
Weak - 0 pointsAll contracting remains pure fee-for-service or capitation without outcome adjustment.
Question 12
Is panel attribution clearly defined for PHM contracts: with documented methodology for which patients are attributed to which provider, attribution stability rules, and reattribution processes?
Strong - 3 pointsPanel attribution methodology is formally documented, stable over defined periods, and accepted by both contracting parties.
Partial - 2 pointsAttribution exists but methodology is not formally documented or is inconsistently applied.
Weak - 0 pointsNo formal panel attribution. PHM contracting is not feasible without this foundation.
Question 13
Is risk adjustment incorporated into PHM contracts: ensuring that providers managing higher-acuity patients are not financially penalised relative to those managing lower-acuity panels?
Strong - 3 pointsRisk adjustment methodology is documented, technically rigorous, and accepted by both contracting parties. Quality-adjusted comparison is feasible.
Partial - 2 pointsRisk adjustment is acknowledged as necessary but methodology is informal or contested.
Weak - 0 pointsNo risk adjustment in contracting. Higher-acuity panels are financially disadvantaged.
Question 14
Has the AR-DRG transition impact on PHM economics been formally analysed: addressing how bundled inpatient payments interact with population-based PHM payments at the cohort level?
Strong - 3 pointsFormal AR-DRG and PHM interaction analysis has been completed with quantified financial implications and contracting model adjustments planned.
Partial - 2 pointsThe interaction is recognised but formal analysis with documented financial implications has not been completed.
Weak - 0 pointsThe AR-DRG and PHM interaction has not been analysed. The two reforms are treated as separate streams.
Question 15
Is contracting infrastructure adequate to scale PHM: with standardised contract templates, defined performance metrics, and a contracting team with PHM-specific expertise rather than general claims contracting capability?
Strong - 3 pointsPHM contracting infrastructure is operational with standardised templates, specialised contracting expertise, and scalable processes.
Partial - 2 pointsSome PHM contracting capability exists but each contract is largely bespoke without standardised infrastructure.
Weak - 0 pointsNo PHM-specific contracting capability. All contracts are managed through general claims contracting processes.
Section 4 of 5
Financial Measurement & Outcome Validation
Tests whether your PHM impact measurement can withstand actuarial and regulatory scrutiny: whether outcomes are measured against defensible counterfactual baselines rather than retrospectively constructed comparisons.
Is PHM financial impact measured against a documented counterfactual baseline: a comparable cohort under standardised methodology, rather than retrospectively constructed comparisons?
Strong - 3 pointsCounterfactual baseline methodology is documented, pre-specified before interventions begin, and would withstand external actuarial scrutiny.
Partial - 2 pointsSome baseline comparison exists but methodology is constructed after the fact or is not actuarially defensible.
Weak - 0 pointsPHM impact claims are not measured against a structured counterfactual baseline.
Question 17
Are PHM outcome measures aligned with the IA Risk-Based Capital framework requirements: ensuring that cohort risk profile changes can be incorporated into actuarial capital adequacy calculations?
Strong - 3 pointsPHM outcome measurement is structured to feed RBC actuarial models, with risk profile evidence appropriate for capital adequacy reporting.
Partial - 2 pointsSome alignment with RBC requirements exists but measurement is not fully integrated with actuarial calculations.
Weak - 0 pointsPHM outcome measurement is disconnected from the actuarial framework.
Question 18
Is total cost of care measured for PHM cohorts: integrating medical, pharmacy, and supplementary service costs into a unified per-patient-per-period figure?
Strong - 3 pointsTotal cost of care is measured monthly across all categories, integrated into a unified analytical view, and used in programme decision-making.
Partial - 2 pointsCost is measured but in silos (medical, pharmacy) without integration into a unified PHM cohort view.
Weak - 0 pointsNo integrated total cost of care measurement for PHM cohorts.
Question 19
Are clinical outcomes measured alongside financial outcomes: glycemic control, blood pressure control, cardiovascular event rates, mortality, and similar clinical endpoints relevant to the targeted conditions?
Strong - 3 pointsClinical and financial outcomes are measured together with consistent methodology, reviewed jointly, and used to evaluate programme impact.
Partial - 2 pointsClinical outcomes are tracked but not integrated with financial measurement, or coverage is partial.
Weak - 0 pointsClinical outcomes are not measured as part of PHM impact assessment.
Question 20
Is PHM impact independently auditable: with documentation, data lineage, and methodology that would support third-party validation if required by regulators or contracting partners?
Strong - 3 pointsPHM impact measurement is fully documented with data lineage, methodology specifications, and audit trail supporting external validation.
Partial - 2 pointsDocumentation exists but is incomplete or methodology is not fully reproducible by external review.
Weak - 0 pointsPHM impact measurement is not independently auditable.
Section 5 of 5
Governance Architecture
Evaluates whether PHM operates with the organisational architecture required to deliver sustained impact: named accountability, board reporting, strategic alignment, and integration with the broader reform environment.
Tests against: PHM as Project · Capability Without Sustainability
Question 21
Is there a named senior executive accountable for Population Health Management as a distinct discipline: with authority over cohort identification, clinical pathway design, contracting decisions, and outcome measurement?
Strong - 3 pointsA named senior executive holds PHM accountability with documented authority across all five PHM capability domains and direct board reporting.
Partial - 2 pointsPHM responsibility is distributed across multiple functions without a single named executive accountability.
Weak - 0 pointsNo named PHM accountability. PHM activities are managed within general claims or clinical operations.
Question 22
Does the board or board-level committee receive regular PHM reporting: covering cohort coverage, clinical outcome trends, financial impact, and progress against the CHI five-condition strategy?
Strong - 3 pointsQuarterly PHM reporting reaches board level with structured coverage of all four reporting dimensions and explicit decisions on programme direction.
Partial - 2 pointsSome PHM reporting reaches leadership but not as a structured cycle covering the key dimensions.
Weak - 0 pointsPHM is not reported to the board. The programme operates without strategic visibility.
Question 23
Has the PHM strategy been formally aligned with the broader Saudi reform environment: AR-DRG transition, NISS expansion, IA RBC framework, and the CHI five-condition PHM strategy as published?
Strong - 3 pointsStrategic alignment with each reform driver is documented, with specific operational implications mapped and incorporated into the PHM programme design.
Partial - 2 pointsThe reform environment is acknowledged but specific alignment has not been formally documented.
Weak - 0 pointsPHM strategy operates without formal alignment to the reform environment.
Question 24
Is PHM investment treated as a strategic capability build rather than an operational expense: with multi-year budget, capability roadmap, and milestones tied to strategic outcomes?
Strong - 3 pointsA multi-year PHM investment plan exists with strategic capability roadmap, milestone-tied investments, and board-approved budget allocation.
Partial - 2 pointsPHM is funded but on an annual operational basis rather than as a strategic capability build.
Weak - 0 pointsPHM has no dedicated multi-year investment plan.
Question 25
Has PHM staffing been built with the disciplines required: clinical pharmacists, data analysts with clinical coding competency, care coordinators with PHM training, and actuarial expertise: rather than being absorbed into existing operational functions?
Strong - 3 pointsPHM staffing includes all four specialist disciplines, with documented role definitions and competency frameworks. PHM operates as a distinct function.
Partial - 2 pointsSome specialist disciplines are in place but PHM staffing is not yet structured as a distinct function with complete coverage.
Weak - 0 pointsPHM is staffed from existing general claims or clinical operations without specialist disciplines.
PHM Readiness Diagnostic - Results
Your PHM Readiness Profile
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Domain Breakdown
Cohort Identification
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Clinical Pathway Integration
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Contracting Capability
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Financial Measurement
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Governance Architecture
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Indicative Findings
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This self-assessment shows the methodology. The facilitated diagnostic goes further.
A facilitated HealthElevate PHM diagnostic includes NPHIES-data-grounded cohort identification analysis, contracting framework review, and a board-ready PHM capability roadmap aligned to the CHI five-condition strategy and the reform environment.
From Reactive Claims to Population Health: The Strategic Question Most Saudi Insurers Have Not Yet Answered
The analytical context behind this instrument: what the CHI five-condition PHM strategy actually mandates, the multimorbidity reality, three capabilities that distinguish real PHM from performative PHM, and the reform convergence.