UHC Forward: Towards Universal Health Coverage

The EHIF negotiates capped cost and volume contracts with hospitals at the start of each year. These contracts contain provisions on service quality and access, as well as an extended cost and volume section. The contracting process begins with a needs assessment based on historical data regarding health service utilization along with existing waiting times. The EHIF does not have to contract with all providers. Still most of the services are purchased from hospital master plan hospitals with which EHIF has contracts. A small amount of funds go to selective contracting which provides private providers the opportunity to get some health insurance funding. These private providers, however, tend to be primarily funded through OOP payments. A large part of the standard contract conditions are negotiated with the Hospital Association, but there are also financial appendices that are negotiated with each provider individually. Contracts are monitored quarterly using the Management Information System.

Actual payment methods and prices are regulated in a single government health service list that lies outside of the contract negotiation process and which is updated at least once per year. All providers are paid the same prices. The list includes over 2,000 different items and a range of different payment methods. Outpatient care is normally paid on a fee-for-service basis and inpatient care is paid with a mix of fee-for-service, per diem, and diagnosis-related group (DRG) methods.

Primary care family physicians are paid through per capita payments that are adjusted based on the age of the patients. If a family physician has fewer than 1,200 patients, he will still receive a capitation payment for 1,200 patients in order to cover fixed costs. Family physicians can also receive additional fee-for-service payments up to 32% of the capitation amount received. Contracts for family medicine are agreed to between the EHIF and the Estonian Association of Family Doctors. The financial stipulations of the contracts with particular family doctors are reviewed every quarter in order to align with changes in the number of patients on the practice list. Specialist care is also compensated using different types of payment methods depending on the services provided. These methods include fee-for-service, visit fees, per diem, diagnosis-related group, and case-based complex pricing. Since the 1990s, there has been a gradual move away from fee-for service toward case-based payments.

Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. The base primary care capitation rate (before adjustment coefficients) is based on two variables, the estimated number of enrollees that are expected to be enrolled in a family group practice over the coming year, and the size of the budget. The case-based payments for hospital services introduced the idea of output-based payments to the Kyrgyz health system. The system for grouping cases, generally called clinical statistical groups, was based on American diagnosis-related-groups, but was created with Kyrgyz utilization and cost data. This new system enabled an expansion of the budget management autonomy of hospital administrators, although hospital autonomy and management capacity is still an issue on the reform agenda.

The republican MHIF and its territorial branches administer the national pool of funds for the SGBP and are responsible for making all case- and capitation-based payments. Per-case payment rates are defined prospectively but payments are made on a monthly basis. In order to avoid provider selection, providers receive higher payments for treating exempt patients and those with lower copayments. A key to the success of the MHIF as the single-payer for the SGBP has been the continuous development and refinement of financial and clinical information systems to operate the provider payment systems and ensure good financial reporting and fiduciary risk mitigation.

Providers are paid on a by-intervention basis, where a specified rate is set by Aarogyasri Trust in consultation with medical experts. For each approved procedure, the payment covers the entire cost of treatment, from the date of admission to discharge, as well as a maximum of 10 days after the discharge and any complications while in the hospital. The package rate includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges, and post-operative hospital stay.

A comprehensive list of benefits and associated payment pricing can be found on the Aarogyasri web site.

Seeking care is truly cashless for the patient. On the back-end, the provider must submit a pre-authorization to the insurance company (Aarogyasri I procedures) or to Aarogyasri Healthcare Trust (for Aarogyasri II procedures). The insurance company/Trust appoints medical officers who work on pre-authorizations. After pre-authorization and treatment, the insurance company or Trust (depending on which Procedure the beneficiary was enrolled in) will settle claims from hospitals within seven days of receipt of claim, discharge summary, and a satisfaction letter from the patient.

To prevent fraudulent claims, the claim settlement history of each hospital is scrutinized and reviewed by the Trust at regular intervals. In addition, the insurance company recruits specialized doctors, known as vigilance officers, for regular inspection of hospitals. These specialists also attend to complaints from beneficiaries directly or through Arogya Mithras for any deficiency in services reported. The specialists also to ensure proper care and counseling for the patient at network hospitals by coordinating with Aarogya Mithras and hospital authorities.