Health benefit utilization and out-of-pocket expenses in outpatient care and hospitalizations: Baseline surveys of three primary care sites in the Philippines

Background@#The Philippine Primary Care Studies (PPCS) is a network of pilot studies that developed, implemented, and tested strategies to strengthen primary care in the country. These pilot studies were implemented in an urban, rural, and remote setting. The aim is to use the findings to guide the policies of the national health insurance program (PhilHealth), the main payor for individualized healthcare services in the country.@*Objective@#The objective of this report is to compare baseline outpatient benefit utilization, hospitalization, and health spending, including out-of-pocket (OOP) expenses, in three health settings (urban, rural, and remote). These findings were used to contextualize strategies to strengthen primary care in these three settings.@*Methods@#Cross-sectional surveys were carried out using an interviewer-assisted questionnaire on a random sample of families in the urban site, and a stratified random sample of households in the rural and remote sites. The questionnaire asked for out-patient and hospitalization utilization and spending, including the OOP expenses. @*Results@#A total of 787 families/households were sampled across the three sites. For outpatient benefits, utilization was low in all sites. The remote site had the lowest utilization at only 15%. Unexpectedly, the average annual OOP expenses for outpatient consults in the remote site was PhP 571.92/per capita. This is 40% higher than expenses shouldered by families in the rural area, but similar with the urban site. For hospital benefits, utilization was lowest in the remote site (55.7%) compared to 75.0% and 78.1% for the urban and rural sites, respectively. OOP expenses per year were highest in the remote site at PhP 2204.44 per capita, probably because of delay in access to healthcare and consequently more severe conditions. Surprisingly, annual expenses per year for families in the rural sites (PhP 672.03 per capita) were less than half of what families in the urban sites spent (PhP 1783.38 per capita). @*Conclusions@#Compared to families in the urban site and households in the rural sites, households in remote areas have higher disease rates and consequently, increased need for outpatient and inpatient health services. When they do get sick, access to care is more difficult. This leads to lower rates of benefit utilization and higher out-of-pocket expenses. Thus, provision of “equal” benefits can inadvertently lead to “inequitable” healthcare, pushing disadvantaged populations into a greater disadvantage. These results imply that health benefits need to be allocated according to need. Families in poorer and more remote areas may require greater subsidies.

Expanding healthcare coverage: An experience from Rashtriya Swasthya Bima Yojna

Background & objective: Given that Ayushman Bharat Yojna was launched in 2018 in India, analysis of Rashtriya Swasthya Bima Yojna (RSBY) become relevant. The objective of this study was to examine the scheme design and the incentive structure under RSBY. Methods: The study was conducted in the districts of Patiala and Yamunanagar in the States of Punjab and Haryana, respectively (2011-2013). The mixed method study involved review of key documents; 20 in-depth interviews of key stakeholders; 399 exit interviews of RSBY and non-RSBY beneficiaries in Patiala and 353 in Yamunanagar from 12 selected RSBY empanelled hospitals; and analysis of secondary databases from State nodal agencies and district medical officers. Results: Insurance companies had considerable implementation responsibilities which led to conflict of interest in enrolment and empanelment. Enrolment was 15 per cent in Patiala and 42 per cent in Yamunanagar. Empanelment of health facilities was 17 (15%) in Patiala and 37 (30%) in Yamunanagar. Private-empanelled facilities were geographically clustered in the urban parts of the sub-districts. Monitoring was weak and led to breach of contracts. RSBY beneficiaries incurred out-of-pocket (OOP) expenditures (?5748); however, it was lower than that for non-RSBY (?10667). The scheme had in-built incentives for Centre, State, insurance companies and health providers (both public and private). There were no incentives for health staff for additional RSBY activities. Interpretation & conclusions: RSBY has in-built incentives for all stakeholders. Some of the gaps identified in the scheme design pertained to poor enrolment practices, distribution of roles and responsibilities, fixed package rates, weak monitoring and supervision, and incurring OOP expenditure.

Systematic Review Of Factors Associated With Willingness To Pay For Health Financing Scheme

@#Health care has emerged as one of the fastest growing industry worldwide. This induced health care costto rise tramendously. However, it is important to preserve high quality health care services that are equitable and affordable. In many countries, people are expected to contribute to the cost of the health care. Are populations ready to accept the concept and willing to pay for health financing scheme? What possible factors that may associate with their decision? This is the objective of the study, to examine the relevance evidence for this through a systematic review of literatures.We systematically searched Ovid MEDLINE and Google Schoolar databases until April 2016. We assessed the study population willingness to pay for health financing scheme and determine the significant variables that associate with WTP. 19 full-text articles were included in the review. Factors that were found significantly associated with WTP for health financing scheme by many studies were age, education, income and residential locality. Other factors that also found associated with WTP were health care services utilization and expenditure. The review findings showed that WTP for health financing scheme is beyond the households’ financial capacity and has multifactorial influences.

Medical insurance anti-fraud mechanism from the perspective of cooperative governance: In-ternational experience and implications / 中国卫生政策研究

With the rapid development of China's social insurance,the phenomenon of medical insurance fraud is also increasing,which seriously threatens the comprehensive operation of health insurance funds and medical insur-ance system. Because of the cooperation between the government and the market,Europe & US have accumulated a lot of experience and achieved considerable success in anti-medical fraud as the"harder-hit area"in insurance fraud. This paper discusses the anti-fraud mechanism of foreign medical insurance to establish medical anti-fraud agencies within the government,and give full play to the complementary role of non-profit organizations to strengthen the con-trol and supervision of medical insurance and health care institutions and uses modern information technology to im-prove anti-fraud level.

The need for better evidence to evaluate the health & economic benefits of India’s Rashtriya Swasthya Bima Yojana.

In this review the existing evidence on the impact of Rashtriya Swasthya Bima Yojana (RSBY) is discussed in the context of international literature available on health insurance. We describe potential pathways through which health insurance can affect health and economic outcomes, discuss evidence from other developing countries, and identify potential biases and inconsistencies in existing studies on RSBY impact. Given the relatively recent introduction of RSBY, lack of quality, verifiable data on utilization patterns, and the absence of reliable evaluation studies, there is a need to exercise caution while assessing the merits of the programme. Considering the enormous potential and cost of the programme, we emphasize the need for a rigorous impact evaluation of RSBY. It will not only help capture the real impact of the scheme, but may also be able to estimate the extent of systemic inefficiencies at the level of the consumer.

Study on the social functions and roles of public hospitals / 中华医院管理杂志

This paper analyzed the social functions and roles played by public hospitals. Whatever the health system looks like National Health Services or Social Health Insurance, the functions of the public hospitals in society can be summarized as the following: Firstly, they are the providers of medical services with equal access by the residents. Secondly, they are the important components of the medical security system. Thirdly, they are the positive influencing forces in the medical market. Fourthly, they are the security forces for the nation and society. Fifthly, they are the incubator for training of human resources for health and lastly, they are also the developer of medical sciences. Hence, the existence and well-functioning of public hospitals are very crucial to meet the goal of universal coverage for basic health demands of the whole population.