Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal

Background: Nepal’s national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9 percent and 38 percent respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with social health insurance program dropout in Pokhara, Nepal. Methods: A cross-sectional household survey of 355 households enrolled for at least one year in the national social health insurance program was conducted. A structured questionnaire was used to conduct face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with social health insurance program dropout were identified using bivariate and multiple logistic regression analyses. Results: The findings of the study revealed a dropout prevalence of 28.2% (95% confidence interval: 23.6%-33.2%). Households having more than five members [adjusted odds ratio (aOR) 2.19, 95% CI: 1.22-3.94], belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95%CI 1.87-10.95), absence of chronic illness in family (aOR 1.95, 95%CI: 1.07-3.59), perceived good health status of the family (aOR 4.21, 95%CI: 1.21-14.65), having private health facility as first contact point (aOR 3.75, 95%CI: 1.93-7.27), poor availability of drugs (aOR 4.75, 95%CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR 3.09, 95%CI: 1.01- 9.49) were statistically significant factors associated with SHI dropout. Conclusion: In Pokhara, more than one-fourth of households have dropped out of the Social Health Insurance Scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members’ reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers’ behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

Medico-economic impact of enhanced rehabilitation after surgery: an exhaustive, nation-wide claims study

Background Study of the medico economic impact of enhanced rehabilitation after surgery (ERAS), by comparing the cost of patient care with or without ERAS, both from the point of view of the hospitals and the Social Security Health Insurance Program. Methods Retrospective longitudinal study on matched data from March 1, 2019 to December 31, 2019. The data are extracted from the French prospective payment system. We studied 12 of the most commonly performed in ERAS business segments. The primary outcome was the reduction of the average length of hospital stay and its implications on production costs and excess capacity. We also studied the impact on hospital incomes and Social Security Insurance Program expenses. The potential gain in hospital days was computed by comparing the length of stay of ERAS and non-ERAS cases. The cost reduction was estimated using the mean number of avoidable days of hospitalization, and the mean cost of the stays obtained from the national cost study. Finally, we studied an approximation of the additional expense for the Social Security Health Insurance Program on costs standardized by applying public sector rates. Results The average length of stay reduction attributed to ERAS is 1.45 (CI 95% 1.42 to 1.48) day per stay, translating to a cost reduction for the hospitals of € 1060 (CI 95% 995 to 1125) per patient and a total of €65 million (CI 95% 61 to 69). At the same time, the additional expenses for the Social Security Insurance Program can conservatively be approximated to € 1.6 million, breaking into a € 2.2 million increase partially compensated by cost savings of € 0.6 million over subsequent stays for complications. Overall, for each percent of additional ERAS activity over the scope of the study, the marginal cost reduction for the hospitals can be estimated to € 1.8 million (CI 95% 1.7 million to 2.0 million). Conclusions Associated with previously known clinical benefits for the patients, these convincing results in terms of economic gain strongly support expanding the adoption of ERAS.

National Health Insurance Program financing during the COVID-19 pandemic: financial viability and

This paper examines the state of National Health Insurance Program (NHIP) financing during the COVID-19 pandemic in the Philippines, an event which coincides with the implementation of the Universal Health Care (UHC) mandates on restructuring the NHIP premium schedule, providing immediate eligibility to NHIP benefits, and expanding member benefits. Using the ratio of total expenditures to total revenues as the measure of financial viability, it shows that the NHIP remains financially viable during the COVID-19 pandemic year of 2020. Projections for 2021 however show that NHIP financial viability may be adversely affected by the significantly higher number of COVID-19 cases with the negative effect mitigated only if COVID-19 benefit claim patterns remain as weak as observed for 2020. On the revenue side, the potential for a lower premium is observed to be offset by the higher rates in the UHC mandated premium schedule. On the expenditure side, potential increases associated with the implementation of immediate eligibility and the introduction of COVID-19 benefits are mitigated by lower NHIP benefit utilization due to reduced mobility and access to health facilities. Secondary analysis on who has to bear the burden of paying for NHIP benefits, however, shows that the implementation of UHC financing initiatives may heighten adverse incentives on members’ willingness to pay premiums. Using the benefit expenditure-premium contribution ratio as the measure for the burden of paying for NHIP benefits, it is shown that the Formal Economy sector shoulders the burden of funding the NHIP benefits of the Informal Economy and Sponsored sectors.

The Challenges of Universal Health Insurance in Developing Countries: Experimental Evidence from Indonesia’s National Health Insurance

To investigate barriers to universal health insurance in developing countries, we designed a randomized experiment involving about 6,000 households in Indonesia who are subject to a government health insurance program with a weakly enforced mandate. Time-limited subsidies increased enrollment and attracted lower-cost enrollees, in part by reducing the strategic timing of enrollment to correspond with health needs. Registration assistance also increased enrollment, but increased attempted enrollment much more, as over one-half of households who attempted to enroll did not successfully do so. These findings underscore how weak administrative capacity can create important challenges in developing countries for achieving widespread coverage. (JEL D82, G22, H51, I13, I18, O15)

The Analysis of Differences in Hospital Rill Rates and INA-CBG's Rate on Sectio Caesare Action in RSU. Imelda Pekerja Indonesia Medan 2019

The Indonesian government has developed a Health Insurance program National Social Security Administering Bodies (BPJS) Health. One of the ways to pay for health services for hospitals in Era JKN is the Indonesian Case Base Groups (INA-CBG's) payment system, namely the amount of claim payment by BPJS Health to the hospital for the package services based on diagnosis of disease and procedures. This study aims to analyze hospital real rates and INA CBG rates on the action of sectio caesarea and to find out the efforts made hospitals to cover INA-CBG's shortfall in claims costs. Types of research Qualitative descriptive conducted by in-depth interviews. Research sites at the hospital. Imelda Indonesian Worker having his address at Jalan Bilal No. 24 Kelurahan Pulo Brayan Darat I, East Medan District. The research was carried out since months January 2019 until finished. The population in this study is claim data delivery of inpatients who performed sectio casearea at month March and April as many as 143 cases The samples in this study were all population of 143 cases. The results showed that the difference in real rates hospital and INA-CBG rates on Sectio Caesaria at RSU. Imelda Worker Indonesia Medan in 2019 amounted to 73% of the real hospital rates exceeding the tariff INA-CBG's with a total difference in costs reaching IDR 199,661,028. and 39% real hospital fee less than INA-CBG's package rate. Efforts are conducted by the RSU. Imelda Indonesian workers to cover the shortage of costs INA-CBG's claims include using students who come from schools Imelda's own foundation, set the Sectio Caesare service package on general patients and providing supporting facilities. Suggested to RSU. Imelda Indonesian workers evaluate the financial risks received from services Sectio Caesare and evaluating the distribution of INA-CBG's claim costs for services Sectio Caesare is up to standard.