UHC Forward: Towards Universal Health Coverage

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.

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.