UHC Forward: Towards Universal Health Coverage

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.

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.