Expenses and national insurance payments at a municipal-level hospital in rural Nepal: implications for strategic purchasing and universal health coverage

2020 ◽  
Author(s):  
Ryan Schwarz ◽  
Prajwol Nepal ◽  
Bibhav Acharya ◽  
Shiva Raj Adhikari ◽  
Anu Aryal ◽  
...  
Keyword(s):  
Health Care ◽  
Private Sector ◽  
Hospital Costs ◽  
Fee For Service ◽  
Health Coverage ◽  
Outpatient Services ◽  
Strategic Purchasing ◽  
Health Delivery ◽  
Provider Payment ◽  
Payment Mechanisms

Abstract Background: Strategic purchasing mechanisms, including national health insurance, provide opportunities to improve quality and progress towards universal health coverage. Nepal’s health insurance program (HIP), begun in 2016, is a national insurance platform aiming to improve financial risk protection, and efficiency, quality, and access to health services. HIP also further engages private-sector providers through strategic purchasing, potentially improving quality, regulation, and accountability. Bayalpata Hospital is a public-private partnership (PPP) hospital run jointly by the Ministry of Health and Population and Nyaya Health Nepal and is one of the first PPP hospitals enrolled in HIP. We evaluated Bayalpata Hospital costs and HIP guidelines to understand how HIP rates compare to health delivery costs incurred.Methods: We employed a top-down costing methodology to analyze costs for fiscal year 2017-2018. We compared costs to HIP reimbursement rates during the same period, and projected overall coverage for costs assuming full HIP enrollment given the compulsory nature of HIP.Results: Our data suggest HIP, as one payment mechanism in Nepal’s mixed provider payment system, would cover 57% of hospital costs with full enrollment, with variation across services. Among inpatient services, 64% of costs would be covered, including 105% reimbursement for fee-for-service, 87% reimbursement for bundled packages, but only 23% - 40% for certain surgical services. For outpatient services, 59% would be covered, and for emergency services, 32% would be covered. Conclusions: HIP is an important strategic purchasing foundation; however, payments may be insufficient to match provider costs and cover a larger percentage of inpatient-based and fee-for-service delivery than outpatient services. These dynamics may inappropriately incentivize fee-for-service health care utilization, in particular for private-sector providers without access to other public-sector payment mechanisms, while potentially disincentivizing outpatient or community-based approaches to health care, which are less well reimbursed through HIP. HIP policy revisions, and further expansion of mixed provider payment mechanisms, may more effectively incentivize primary health care approaches, while also deepening private-sector engagement. The data and experience of Bayalpata Hospital and HIP offer practical insights for Nepali policymakers and those in similar settings globally employing strategic purchasing to improve progress towards UHC and quality health delivery.

scholarly journals Standard Survey Data: Insights Into Private Sector Utilization

2021 ◽  
Vol 8 ◽  
Author(s):  
Dominic Montagu ◽  
Nirali Chakraborty
Keyword(s):  
Private Sector ◽  
Inpatient Care ◽  
Healthcare Services ◽  
Health Coverage ◽  
Outpatient Services ◽  
Health Seeking ◽  
Data Set ◽  
Middle Income ◽  
Global Trends ◽  
Private Care

Universal Health Coverage in Low- and Middle-Income Countries is increasingly expanding through incorporation of private clinics, pharmacies, and hospitals into an overall health system funded in whole or part through government-managed health insurance. This underscores the importance of policies on health provision which apply across the whole delivery system regardless of ownership status. To advance understanding of private-sector policies, and to facilitate sharing of lessons across countries with similar public-private distributions, we have analyzed data on the source of inpatient and outpatient care from 65 countries. While past studies have conducted similar analysis, ours advances the field in two ways. First, we limit our analysis to data sets from 2010 through 2019, making our study more up-to-date than past studies, while changing health seeking patterns for maternal health since 2010 means that our data set is more representative of overall inpatient care. Second, while past multi-country analysis of public-private ownership have been based on the Demographic Health Surveys, we have added to this data from the Multiple Indicator Cluster Surveys, significantly increasing the countries in our analysis. We have aggregated our analysis by WHO's regions. Outside of the EURO region, where the private sector delivers just 4% of all healthcare services, the private sector remains significant, and in many countries represents more than half of all care. The private sector provides nearly 40% of all healthcare in PAHO, AFRO, and WPRO regions, 57% in SEARO, and 62% in EMRO. While specific countries with two recent surveys show variation in the scale of both inpatient and outpatient private provision, we did not find regional or global trends toward or away from private care within LMICs. Private inpatient care is most important for the wealthy in many countries; public vs. private care varies less, by wealth, for outpatient services.

Association of SHI coverage and level of healthcare utilization and costs in the Philippines: a 10-year pooled analysis

2019 ◽  
Vol 42 (4) ◽  
pp. e496-e505
Author(s):  
Nel Jason L Haw ◽  
Jhanna Uy ◽  
Beverly Lorraine Ho
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Health Care Utilization ◽  
Health Care Costs ◽  
Inpatient Care ◽  
The Philippines ◽  
Care Utilization ◽  
Health Coverage ◽  
Outpatient Services ◽  
Care Costs

Abstract Background The Philippine Health Insurance Corporation (PhilHealth), which manages the Philippine national health insurance program, is a critical actor in the country’s strategy for universal health coverage. Over the past decade, PhilHealth has passed significant coverage, benefits and payment reforms to contain costs and improve the affordability care for high-cost diseases, inpatient care and select outpatient services. Methods We studied the association of PhilHealth with health care utilization and health care costs using three rounds of the Philippine Demographic and Health Survey with data on individual outpatient and inpatient visits from 2008 to 2017. Results PhilHealth membership was associated with 42% greater odds of outpatient utilization and 47–100% greater odds inpatient utilization depending on survey year. Depending on facility type, use of PhilHealth to pay for care was associated with higher average health care costs of 244–865% for outpatient care and 135–206% for inpatient care. Conclusions PhilHealth has likely decreased barriers to health care utilization but may have inadvertently driven up health care costs in the country. Results align with past studies that suggest that reforms in the prior decade have done little to contain health care costs for Filipinos.

scholarly journals Performance of private sector health care: implications for universal health coverage

The Lancet ◽  
2016 ◽  
Vol 388 (10044) ◽  
pp. 606-612 ◽  
Author(s):  
Rosemary Morgan ◽  
Tim Ensor ◽  
Hugh Waters
Keyword(s):  
Health Care ◽  
Private Sector ◽  
Universal Health Coverage ◽  
Health Coverage ◽  
Universal Health

scholarly journals More than 70 Percent of Insured Patients are Paying Informally During Outpatient Visits? Country Wide Evidence from Iran

2020 ◽  
Author(s):  
Haniye Sadat Sajadi ◽  
Farkhondeh Alsadat Sajadi ◽  
Maryam Yaghoubi ◽  
Reza Majdzadeh
Keyword(s):  
Health Care ◽  
Private Sector ◽  
Health Expenditure ◽  
Service Providers ◽  
Outpatient Service ◽  
Total Health Expenditure ◽  
Outpatient Services ◽  
Informal Payments ◽  
The Public ◽  
Insured Patients

Abstract Background: Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), to finance total health expenditure has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spending on outpatient services, there is scant evidence of the amount paid informally by patient in outpatient services. Such evidence is available for inpatient services, showing high prevalence of informal payments, ranging from 7-10% in a hospital department to 20-48% in the whole hospital. This study aimed to investigate the extent of IPs for outpatient services in Iran.Methods: Data used were drawn from the 2015 IR. Iran’s Utilization of Health-care Services Survey, with a focus on all individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers. The percentage of OOP and the frequency of IP were determined and the relationships between them and demographic variables were investigated.Results: The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in the public versus 61% in the private sector, while for a specialist practitioner visit the figures were 80% and 96%, respectively, which is higher that defined copayment (=30%). This share was significantly more in female, urban area, high educated people, private service providers, and specialist visits. The frequency of IPs also was 73% for a GP in the public versus 86% in the private sector, while for a specialist practitioner visit these were 90% and 93%, respectively. Conclusion: It seems that informal patient payments for outpatient services is more prevalent for outpatient service. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in private sector. In this regard, making a well-regulated market, reinforcing the referral system and developing an equity-oriented essential health services package would be fundamental.Trial registration: NA

Methods and Measurement of Primary, Secondary and Tertiary Healthcare Expenditures in India During 2013–2014 to 2016–2017

2021 ◽  
pp. 097370302110470
Author(s):  
Charu C. Garg ◽  
Pratheeba John ◽  
Tushar Mokashi
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Private Sector ◽  
Health Care Providers ◽  
National Health ◽  
Tertiary Care ◽  
Health Coverage ◽  
Care Providers ◽  
Care Services ◽  
The Government

Improving investments in primary health care has become a mounting priority in the context of Universal Health Coverage and India’s National Health Policy 2017 goal to provide cost-effective care. The paper uses the India National Health Accounts, health care providers and health care functions classifications, to allocate current health expenditures (CHE) to primary, secondary and tertiary (PST) care and analyse the trends and composition of PST expenditures between 2013–2014 and 2016–2017. Findings reveal that 45.2% of CHE was spent on primary care in 2016–2017. The government spends 52% of its CHE for primary care. Private spending on primary care has declined from 44% to 41% during the study period. Disaggregate analysis shows that 41% of primary care expenditures were on medicines, 29% on curative care and 15% on preventive care services. About 32% of primary care expenditures were spent at government facilities/providers as compared to 10% at private facilities/doctors. Private sector share of secondary care (38%) and tertiary care (75%) reinforces the role of private sector in providing secondary and tertiary care services. In cognisance of national and international goals, an additional investment of 0.7% of gross domestic product or additional US$11 (₹754) per capita would be required in primary care.

High US Health-Care Spending and the Importance of Provider Payment Rates

2012 ◽  
Vol 15 (3) ◽  
pp. 1-22 ◽  
Author(s):  
Gerard Anderson ◽  
Kalipso Chalkidou ◽  
Bradley Herring
Keyword(s):  
Health Care ◽  
Private Sector ◽  
Health Care Spending ◽  
Industrialized Countries ◽  
Physician Services ◽  
Physician Visits ◽  
The Public ◽  
Provider Payment ◽  
The Usa ◽  
Hospital Days

Abstract We compare health care spending in the USA to other industrialized countries and find that payment rates for hospitals, physicians, and drugs are generally much higher in the USA than they are in other industrialized countries while the quantity of services – as measured by the number of physician visits, hospital days and prescriptions filled per capita – is relatively similar across countries. We then explore policy initiatives designed to control payment rates and volume of services and review the success and failures of these initiatives. Within the USA, the private sector pays significantly higher rates for hospital and physician services and drugs than the public sector. Thus, if the USA is going to reduce health care spending, it may be necessary to begin by reducing payment rates in the private sector. Options to achieve this goal are presented.

The Evolution of Physician Credentialing into Managed Care Selective Contracting

1996 ◽  
Vol 22 (2-3) ◽  
pp. 173-203
Author(s):  
John D. Blum
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Care Delivery ◽  
Fee For Service ◽  
Health Delivery ◽  
Payment Incentives ◽  
Legal Perspective ◽  
American Health Care ◽  
Vantage Points ◽  
Hospital Medical Staff

In a field littered with analogies, health care in the mid-nineties is best characterized as an enterprise caught in the violent cross winds of a tropical storm known as managed care. Like a series of hurricanes, managed care has reshaped the landscape of health care delivery in drastic and unpredictable ways. While the forces of managed care have increasingly altered more health care markets, others are only beginning to feel the winds of change. As managed care overtakes fee-for-service (FFS) medicine, profound alterations in health delivery are occurring which affect every aspect of American health care.Particularly noteworthy is the use of capitation as a primary method of reimbursement. The ramifications of capitated health care are broad and warrant exploration from several vantage points. One basic concern in capitated health plans and managed care is the effect of new payment incentives on physician evaluation for purposes of credentialing. This Article focuses on managed care credentialing—the process of appointing, reappointing, and delineating clinical privileges—from a legal perspective. While the Article centers on the link between capitation and credentialing, it has broader applicability in that the same physician evaluation mechanisms in capitated settings are found in discounted FFS arrangements as well. The piece provides a brief overview of capitation and credentialing, and a discussion of trends that have altered hospital medical staff credentialing processes.

Sign in / Sign up

Export Citation Format

Share Document