Santiago, N. R. (2019). Assessing the provider payment scheme most beneficial for the National Health Insurance Program for Filipinos (Unpublished master's thesis). Public Management Development Program, Development Academy of the Philippines.

Public Management and Development Program Senior Executive Class Batch 7 Thesis (SEC)--Development Academy of the Philippines.

With the Universal Health Care (UHC) Bill almost signed into law, PhilHealth is in the forefront of its implementation. The success of the UHC law can be measured by three indicators that correspond to the achievement of the three dimensions of the UHC cube: To address the two dimensions of benefit coverage and support value (see Figure 1), the provider payment scheme plays a significant role in influencing the behavior of the provider. This is the rationale of my capstone paper, which sought to address this problem: Is the current provider payment scheme responsive to the UHC goals that PhilHealth intends to achieve? PhilHealth started with the fee-for-service (FFS) provider payment scheme upon its inception in February 1995. In September 2011, there was a shift to a case-based payment (CBP) scheme for 23 cases comprising about half of the number of claims. The purpose of the shift was to increase the support value by increasing the benefit payout and imposition of fixed copayment. This resulted in the doubling of benefit payouts for the 23 cases. However, despite the increase in benefit payouts, because the fixed copayment policy was not put in place, it created an inflationary effect on the medical costs, i.e, the providers still charged the relatively the same amount of fees on the top of PhilHealth benefits. This is a failure on the part of the government. Furthermore, there are also market failures-moral hazzard, abuse of market power, and information asymmetry. To address these government and market failures, one of the policy changes neccessary is the use of a provider payment scheme that will be most beneficial to all stakeholders, principally the members, provider's, and insurer, and most applicable to the Philippine hospital system. Assessment and evaluation of the different policy alternatives were conducted and the recommended payment schemes will depend on the setting of the benefit. For the primary care/outpatient setting, a combination of CBP and global budget (GB) schemes are suggested.