The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Provider Payment Mechanisms | Provider payment mechanisms |
|---|---|---|
| Mali: Mutuelles |
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In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. Read full sectionIn Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational. MutuellesProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational. |
| Rwanda: Mutuelles de Sante |
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The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI. Read full sectionThe health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.
On the supply side, financing flows from the central government towards health providers through multiple block grants, which provide hospitals with greater degrees of autonomy. A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers.
A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers. In addition, the substantial amount of donor funding incurs high overhead costs and involves a lack of clarity. Mutuelles de SanteProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.
On the supply side, financing flows from the central government towards health providers through multiple block grants, which provide hospitals with greater degrees of autonomy. A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers.
A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers. In addition, the substantial amount of donor funding incurs high overhead costs and involves a lack of clarity. |
| Korea, Rep.: National Health Insurance Program |
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Providers have historically been reimbursed by the regulated fee-for-service system since the beginning of the national health insurance program (NHIP). There is no difference between public and private providers from the health insurer side regarding fee schedules or reimbursement rates. The fee-for-service system has led to an increase in volume and intensity of services in the long run. However, because fee regulation is applied to all providers, both public and private, it has contributed to overall cost containment and a rapid extension of population coverage. South Korea has single pooled purchasing, and claim reviews and payments are centralized and monitored by the Ministry of Health and Welfare (MoHW). Read full sectionProviders have historically been reimbursed by the regulated fee-for-service system since the beginning of the national health insurance program (NHIP). There is no difference between public and private providers from the health insurer side regarding fee schedules or reimbursement rates. The fee-for-service system has led to an increase in volume and intensity of services in the long run. However, because fee regulation is applied to all providers, both public and private, it has contributed to overall cost containment and a rapid extension of population coverage. South Korea has single pooled purchasing, and claim reviews and payments are centralized and monitored by the Ministry of Health and Welfare (MoHW). In 1997 the government launched a Diagnosis Related Group Pilot program for voluntary participating health facilities. The pilot program showed positive impacts on the behavior of health providers, such as the reduction in the length of stay, medical expenses, the average number of tests and a decreased use of antibiotics. However, there is strong opposition from providers, which has blocked the extension of DRG as a provider payment mechanism throughout the country. The pharmaceutical dispensing was separated from prescribing in 2000. This bars pharmacists from selling antibiotics to customers without a prescription. As such, physicians are not allowed to dispense medicines. National Health Insurance ProgramProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service Providers have historically been reimbursed by the regulated fee-for-service system since the beginning of the national health insurance program (NHIP). There is no difference between public and private providers from the health insurer side regarding fee schedules or reimbursement rates. The fee-for-service system has led to an increase in volume and intensity of services in the long run. However, because fee regulation is applied to all providers, both public and private, it has contributed to overall cost containment and a rapid extension of population coverage. South Korea has single pooled purchasing, and claim reviews and payments are centralized and monitored by the Ministry of Health and Welfare (MoHW). In 1997 the government launched a Diagnosis Related Group Pilot program for voluntary participating health facilities. The pilot program showed positive impacts on the behavior of health providers, such as the reduction in the length of stay, medical expenses, the average number of tests and a decreased use of antibiotics. However, there is strong opposition from providers, which has blocked the extension of DRG as a provider payment mechanism throughout the country. The pharmaceutical dispensing was separated from prescribing in 2000. This bars pharmacists from selling antibiotics to customers without a prescription. As such, physicians are not allowed to dispense medicines. |
| Philippines: PhilHealth |
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Provider payment methods differ based on the type of care delivered. Fee-for-service reimbursements are used for inpatient care, most day surgeries, and ambulatory procedures, while primary care providers are reimbursed based on a capitation system. Read full sectionProvider payment methods differ based on the type of care delivered. Fee-for-service reimbursements are used for inpatient care, most day surgeries, and ambulatory procedures, while primary care providers are reimbursed based on a capitation system. For TB-DOTS treatment, malaria care, deliveries, surgical contraception, and cataract surgeries, a case-based payment methodology is utilized. There is no formal system that sets fixed deductibles or co-payments for beneficiaries, but health care providers are allowed to “balance bill”, charging patients the balance between what PhilHealth pays and the total cost of care. This is atypical of most government health programs around the world and can lead to abuse by providers (e.g., overcharging) and thus limited access for the poorest. At the same time, balance billing allows providers additional cost recovery in the case that the reimbursement for services does not cover their cost. Quality: PhilHealth currently leverages internally developed quality standards. A new set of standards called the “PhilHealth Benchbook” was implemented starting January 1, 2010. The Benchbook was developed by PhilHealth with the assistance of various international health partners and several rounds of consultations with health providers. The previous and new quality standards are overseen by PhilHealth. The new quality standards focus on the following domains of quality of care: patient rights and organizational ethic, patient care, leadership and management, human resource management, information management, safe practice and environment, and mechanisms of improving performance. With the implementation of the new standards this year, hospitals can now be accredited for up to 3 years compared with the previous practice of annual accreditation. PhilHealth has accreditation staff who physically check and verify compliance. PhilHealth has also set peer review committees essentially composed of health care providers who review specific cases. PhilHealth has been planning to implement quality-based purchasing but has not executed on this plan as of December 2009. Performance-based Payment: PhilHealth has been developing incentive payments but this work has been focused on payment to health care professionals and not for health facilities. Doctors are usually independent free agents who ‘practice’ in hospitals. Even government physicians who are salaried are allowed to engage in private practice. Thus, PhilHealth payments are split for health professionals and health facilities and efforts to implement case payments essentially focus on bundling the payment for the health facilities. Among PhilHealth’s work in incentive-based payments is a scheme that has been piloted in 30 local government hospitals since 2002 but has not been scaled up. The scheme is called the Quality Improvement Demonstration Study (QIDS). It utilizes clinical vignettes to measure quality of care. If a hospital passes a set quality of care index score, the payment for physicians is increased. Clinical vignettes focus on the management of illnesses of children less than six years of age. Another incentive scheme is increased payment for health professionals practicing in areas where there is a lack of doctors. Claims Processing: The claims processing procedure is still a manual operation. Electronic claims submissions have long been planned but have not been implemented. Hospitals or members fill out claims forms that are then submitted to PhilHealth within 90 days from hospital or health facility discharge. Two forms are usually submitted: First, a form that documents who the member is and premiums paid; and second, a form that details the service provided. Claims are submitted to 17 regional claims processing centers. These centers initially review if the claims are eligible. Review is inputted manually with a number of data encoded into the claims processing information system. Once the claim is approved for payment, checks are prepared for the signature of regional heads. Electronic reimbursements have been planned but have not yet been implemented. PhilHealthProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation Provider payment methods differ based on the type of care delivered. Fee-for-service reimbursements are used for inpatient care, most day surgeries, and ambulatory procedures, while primary care providers are reimbursed based on a capitation system. For TB-DOTS treatment, malaria care, deliveries, surgical contraception, and cataract surgeries, a case-based payment methodology is utilized. There is no formal system that sets fixed deductibles or co-payments for beneficiaries, but health care providers are allowed to “balance bill”, charging patients the balance between what PhilHealth pays and the total cost of care. This is atypical of most government health programs around the world and can lead to abuse by providers (e.g., overcharging) and thus limited access for the poorest. At the same time, balance billing allows providers additional cost recovery in the case that the reimbursement for services does not cover their cost. Quality: PhilHealth currently leverages internally developed quality standards. A new set of standards called the “PhilHealth Benchbook” was implemented starting January 1, 2010. The Benchbook was developed by PhilHealth with the assistance of various international health partners and several rounds of consultations with health providers. The previous and new quality standards are overseen by PhilHealth. The new quality standards focus on the following domains of quality of care: patient rights and organizational ethic, patient care, leadership and management, human resource management, information management, safe practice and environment, and mechanisms of improving performance. With the implementation of the new standards this year, hospitals can now be accredited for up to 3 years compared with the previous practice of annual accreditation. PhilHealth has accreditation staff who physically check and verify compliance. PhilHealth has also set peer review committees essentially composed of health care providers who review specific cases. PhilHealth has been planning to implement quality-based purchasing but has not executed on this plan as of December 2009. Performance-based Payment: PhilHealth has been developing incentive payments but this work has been focused on payment to health care professionals and not for health facilities. Doctors are usually independent free agents who ‘practice’ in hospitals. Even government physicians who are salaried are allowed to engage in private practice. Thus, PhilHealth payments are split for health professionals and health facilities and efforts to implement case payments essentially focus on bundling the payment for the health facilities. Among PhilHealth’s work in incentive-based payments is a scheme that has been piloted in 30 local government hospitals since 2002 but has not been scaled up. The scheme is called the Quality Improvement Demonstration Study (QIDS). It utilizes clinical vignettes to measure quality of care. If a hospital passes a set quality of care index score, the payment for physicians is increased. Clinical vignettes focus on the management of illnesses of children less than six years of age. Another incentive scheme is increased payment for health professionals practicing in areas where there is a lack of doctors. Claims Processing: The claims processing procedure is still a manual operation. Electronic claims submissions have long been planned but have not been implemented. Hospitals or members fill out claims forms that are then submitted to PhilHealth within 90 days from hospital or health facility discharge. Two forms are usually submitted: First, a form that documents who the member is and premiums paid; and second, a form that details the service provided. Claims are submitted to 17 regional claims processing centers. These centers initially review if the claims are eligible. Review is inputted manually with a number of data encoded into the claims processing information system. Once the claim is approved for payment, checks are prepared for the signature of regional heads. Electronic reimbursements have been planned but have not yet been implemented. |
| Thailand: Universal Coverage Scheme |
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UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. Read full sectionUCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. The current payment mechanism for UCS is a mixed system of risk-adjusted capitation for primary care, a DRG-based capped global budget, and fixed rate fees for some services. It should be noted that health promotion and prevention services for all Thai citizens are paid by the UCS. Universal Coverage SchemeProvider payment mechanisms Provider Payment Mechanisms: Capitation UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. The current payment mechanism for UCS is a mixed system of risk-adjusted capitation for primary care, a DRG-based capped global budget, and fixed rate fees for some services. It should be noted that health promotion and prevention services for all Thai citizens are paid by the UCS. |