UHC Forward: Towards Universal Health Coverage

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.

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.

Providers are paid on a fee-for-service basis, with packages defined for each of the covered procedures and interventions. Claims submission and processing is cashless, allowing hospitals and insurers to submit claims and payments online.

The process for reporting and paying claims is designed to be simple and cashless from the perspective of the provider and beneficiary. In general, the process looks as follows:

1. A patient comes to a provider to receive care and goes straight to the RSBY help desk; the patient’s identity is verified via fingerprints
2. The patient visits the doctor who assesses his/her health condition; doctor prescribes a treatment
3. Assistant at RSBY help desk checks whether procedure is in the list of pre-specified packages. Procedures are priced/paid to the provider on a case-based payment system
   a. If procedure is on list, appropriate prescribed package is selected, patient is scheduled for procedure, and the amount to be paid out is blocked
   b. If not on list, help desk checks with insurer to price and get approval to conduct procedure, patient is scheduled for procedure, and the pre-determined amount to be paid is blocked
4. In-patient treatment is provided to the beneficiary.
5. Upon release of beneficiary from hospital, SmartCard is swiped again with fingerprint verification a. Beneficiary is paid by the hospital Rs. 100/- as transportation expense at time of discharge b. The pre-specified cost of procedure is deducted from the amount available on the card
6. After rendering service to patient, hospital sends an electronic report and claim to the insurer/TPA
7. The insurer/TPA reviews the records and information and makes payment to the hospital (electronically) within a specified time period (agreed upon between insurer/TPA and hospital)

At present there are no quality standards being utilized by RSBY, but the national team is working with states and insurers to develop an incentive based quality management system for providers (e.g., a system where hospitals are graded according specific quality parameters and hospitals with better quality are paid at a higher rate by insurers).