Abadu, O. B., Jr. (2016). Making out-of-pocket payments for health care services more predictable to patients (Unpublished master's thesis). Public Management Development Program, Development Academy of the Philippines.

Public Management Development Program Senior Executives Class Batch 4 Thesis (SEC)--Development Academy of the Philippines.

For more than 20 years since its establishment, PhilHealth has emerged as a major actor in enhancing the breadth and depth of access to health care in the Philippines. It has initiated major policy reforms for universal health care. Health insurance coverage, as of June 30, 2015, is more sustainable than ever at 88% of the Philippines population. It ensured a more inclusive coverage for the poor through the Point-of-Care (POC) Enrolment Program in government health care institutions. Most noteworthy is the major reforms in its provider payment system by shifting from a fee-for-service payment scheme to a more predictable and equitable system of case rate payment. Coupled with the No Balance Billing (NBB) Policy, case rate payment aimed to provide full financial risk protection for the poor. Another area of plausible effort is the Z Benefits, where more than 20 benefit packages are given to those with catastrophic illnesses. However, PhilHealth has not fully addressed the problem of financial risk protection. Even if PhilHealth shoulders some of the cost, the direct outlay of cash by a patient who is a PhilHealth member or his qualified dependent, still remains high and is often unpredictable even in public health care facilities. The unpredictability of out-of-pocket (OOP) payments reflects the failure of government to ensure that the poor households who face difficulties in their daily sustenance are able to access adequate and quality health care. Households expenses on medicines and medical products constitute the largest share of out-of-pocket payments that are not eventually reimbursed by PhilHealth. When individuals get sick, the first question that hounds them is how much they would shell out of their impoverished pockets to pay for health services given that most government health care institutions are not administratively capable. Given the inadequacy of services in these facilities, some take the risk of seeking care in private facilities. Because they are unsure of how much they are going to pay in a private health care institution, they are compelled to postpone hospitalization and instead resort to unreliable self-medication. Indubitable, a delay in medical treatment worsens health conditions and subsequently puts heavier financial burden on both PhiHealth and the patient. It is not that they are unwilling to pay a price, but it is because they are uncertain of how much price they have to pay in order to get cured. The unpredictability of out-of-pocket spending is the main issue that this policy paper aimed to address. The premise is that PhilHealth has the capacity to contain the increasing health care cost be becoming a strategic purchaser of health care goods and services given that there is an absence and weak implementation of regulatory functions by various government agencies. The three policy alternatives evaluated were: Fixed Co-Pay, Posting of Fee Schedules, and Implementation of a Drug Price Referencing System (DPRS) in non-Department of Health (DOH) - Retained Hospitals. The five criteria for analyzing the proposed alternatives are effectiveness, efficiency, feasibility, acceptability and unintended consequences...