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 |
|---|---|---|
| Indonesia: Jamkesmas |
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While the Jamkesmas benefit package is standardized at the national level, districts are able to set the reimbursement rates for various services based on local conditions. Though the scheme initially utilized a fee-for-service reimbursement mechanism Jamkesmas began transitioning to a DRG provider payment system in 2009. All hospitals are being incorporated into the DRG payment process by the end of 2010. Read full sectionWhile the Jamkesmas benefit package is standardized at the national level, districts are able to set the reimbursement rates for various services based on local conditions. Though the scheme initially utilized a fee-for-service reimbursement mechanism Jamkesmas began transitioning to a DRG provider payment system in 2009. All hospitals are being incorporated into the DRG payment process by the end of 2010. Jamkesmas has “verificators” in every network hospital. These verificators have been put in place to assure reimbursements are made only for documentable claims with a full medical record. Verificators process claims and send them electronically to the MoH. Verificators have standard review procedures which they follow to document every case. These standards were developed by the MoH. Once the MoH receives the claim, it begins the reimbursement process to providers. While there has been broad experience with contracting public and private providers through the publically-funded schemes, the contract mechanisms have not used reimbursement or payment policies strategically to drive improvements in quality or efficiency. There are examples in maternal health where the current reimbursement system by Jamkesmas has created the wrong incentives for providers, such as not reimbursing midwives for pre-delivery care if there is post-partum hemorrhage. In addition, once a patient is referred to the hospital, the hospital receives a full reimbursement for delivery, while the midwife receives no fee, thereby discouraging midwives from referring patients to hospitals for complications as they would lose income. JamkesmasProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Diagnosis-Related Groups While the Jamkesmas benefit package is standardized at the national level, districts are able to set the reimbursement rates for various services based on local conditions. Though the scheme initially utilized a fee-for-service reimbursement mechanism Jamkesmas began transitioning to a DRG provider payment system in 2009. All hospitals are being incorporated into the DRG payment process by the end of 2010. Jamkesmas has “verificators” in every network hospital. These verificators have been put in place to assure reimbursements are made only for documentable claims with a full medical record. Verificators process claims and send them electronically to the MoH. Verificators have standard review procedures which they follow to document every case. These standards were developed by the MoH. Once the MoH receives the claim, it begins the reimbursement process to providers. While there has been broad experience with contracting public and private providers through the publically-funded schemes, the contract mechanisms have not used reimbursement or payment policies strategically to drive improvements in quality or efficiency. There are examples in maternal health where the current reimbursement system by Jamkesmas has created the wrong incentives for providers, such as not reimbursing midwives for pre-delivery care if there is post-partum hemorrhage. In addition, once a patient is referred to the hospital, the hospital receives a full reimbursement for delivery, while the midwife receives no fee, thereby discouraging midwives from referring patients to hospitals for complications as they would lose income. |
| 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. |
| Ghana: National Health Insurance Scheme (NHIS) |
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In 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. Read full sectionIn 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. This memorandum now forms the basis of all contracts between the health schemes and providers. Claims processing is a manual process, with some automation in enrollment verifications and claims documentation. The amount of the reimbursement is often less than 100%, with some schemes, for example, paying 70% (e.g., Ossu Kottery – urban scheme in higher income area of Accra), others paying as low as 40% (e.g., Dodowah, rural area outside Accra). The balance is supposed to be paid at later date. National Health Insurance Scheme (NHIS)Provider payment mechanisms Provider Payment Mechanisms: Diagnosis-Related Groups In 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. This memorandum now forms the basis of all contracts between the health schemes and providers. Claims processing is a manual process, with some automation in enrollment verifications and claims documentation. The amount of the reimbursement is often less than 100%, with some schemes, for example, paying 70% (e.g., Ossu Kottery – urban scheme in higher income area of Accra), others paying as low as 40% (e.g., Dodowah, rural area outside Accra). The balance is supposed to be paid at later date. |
| Nigeria: National Health Insurance System |
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Patients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. Read full sectionPatients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. For private insurers, this is determined between HMOs and Providers, with oversight from the central government, and referral to specialist care follows guidelines that are managed accordingly. Decree 35 determined that the only lawful payment systems to be included in NHIS are capitation, fee-for-service, per diem, or case payment. A capitation system is the predominant form of provider payment used to pay primary healthcare facilities, while secondary and tertiary healthcare facilities are paid by fee for service and per diem. National Health Insurance SystemProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation Patients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. For private insurers, this is determined between HMOs and Providers, with oversight from the central government, and referral to specialist care follows guidelines that are managed accordingly. Decree 35 determined that the only lawful payment systems to be included in NHIS are capitation, fee-for-service, per diem, or case payment. A capitation system is the predominant form of provider payment used to pay primary healthcare facilities, while secondary and tertiary healthcare facilities are paid by fee for service and per diem. |
| 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. |
| Brazil: Unified Health System (SUS) |
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Primary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. Read full sectionPrimary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. The same method of provider payments is used for both private and public providers under the SUS. Payments for hospital stays and complex procedures are based on Hospital Stay Authorization (AIH) codes. The AIH payment system is a procedure- or service-based rate system that is not linked to resource usage or costs. Fixed values are established per disease and necessary procedures. Hospitals that undertake complex procedures receive additional resources to maintain their facilities. Ambulatory services are paid by the health funds based on Ambulatory Care Units (UCA) plus an additional fixed amount for each service rendered.
Unified Health System (SUS)Provider payment mechanisms Provider Payment Mechanisms: Capitation, Diagnosis-Related Groups Primary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. The same method of provider payments is used for both private and public providers under the SUS. Payments for hospital stays and complex procedures are based on Hospital Stay Authorization (AIH) codes. The AIH payment system is a procedure- or service-based rate system that is not linked to resource usage or costs. Fixed values are established per disease and necessary procedures. Hospitals that undertake complex procedures receive additional resources to maintain their facilities. Ambulatory services are paid by the health funds based on Ambulatory Care Units (UCA) plus an additional fixed amount for each service rendered.
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