Effectiveness of the Philippine Health Insurance Corporation Case Rate System for Thyroidectomy in a Tertiary Government Hospital

ABSTRACT Objective: To determine the effectiveness of the Philippine Health Insurance Corporation (PhilHealth) case rate system in reducing out-of-pocket expenses among non-no balance billing (NBB) patients undergoing thyroidectomy under the Department of Otorhinolaryngology – Head and Neck Surgery of the Baguio General Hospital and Medical Center from February to September 2018. Methods: Design: Prospective Cross- Sectional Setting: Tertiary Government Hospital Participants: Sixty-four (64) randomly selected patients with PhilHealth who underwent thyroidectomy who agreed to participate and reveal their statements of accounts Results: Among the study population, 20% belonged to the no balance billing (NBB) category, with zero out-of-pocket expenses during their confinement. Eighty percent (80%) belonged to the non-NBB category and also incurred zero hospital charges. In addition, there was no significant difference in the individual categories of the hospital expenses between the two groups except for the surgical procedures (p= .018, 95% CI). The accumulated total expenses also did not significantly differ between the two groups (p= .063, 95% CI). The minimum amount billed was PhP 1,984.95, while the maximum amount charged was PhP 38,898.65, with a median of PhP 18,703.28 and interquartile range of PhP 4,251.78 (XU: PhP 20,848.74, XL : PhP 16,596.96). There were no reported out-of-pocket expenses from non-NBB patients. The actual cost of thyroidectomy did not differ significantly from the case rate provided by PhilHealth among all the RVS categories. Conclusion: The PhilHealth case rate system is effective in reducing out-of-pocket expenses among non-NBB patients who underwent thyroidectomy in our institution during the study period. Keywords: out-of-pocket expenses; thyroidectomy; health care financing; health expenditures: universal health coverage

Japan: achieving UHC by regulating payment

The triple goals of Universal Health Coverage (UHC) are to cover the whole population, to reduce patients’ costs, and to expand coverage to all effective services, equitably available to all. This paper analyses the experience of Japan in achieving these goals, focusing on the central role played by the payment system. The payment system, or fee schedule, sets the price of services and pharmaceuticals, as well as the conditions that providers must comply with in order to receive payment. The fee schedule was first introduced following the enactment of social health insurance (SHI) in 1922. Initially, the SHI program covered only manual workers, who comprised a mere 3% of the population. However, the fee schedule of the largest SHI plan was subsequently adopted by all other SHI plans. From 1958, there has been only one fee schedule. Population coverage was achieved in 1961 by mandating all residing in Japan to enroll in SHI, thereby making everyone entitled to all the services and pharmaceuticals listed in the fee schedule. Next, co-insurance was capped to an affordable level by the introduction of catastrophic coverage in 1973. Lastly, extra billing and balance billing were explicitly restricted in 1984. The key to achieving and sustaining UHC goals in Japan lies in being able to contain costs and reallocate resources by revising the fee schedule.

Twenty-First Century Pathologists' Advocacy

Pathologists' advocacy plays a central role in the establishment of continuously improving patient care quality and patient safety, and in the maintenance and progress of pathology as a profession. Pathology advocacy's primary goal is the betterment of patient safety and quality medical care; however, payment is a necessary and appropriate component to both, and has a central role in advocacy. Now is the time to become involved in pathology advocacy; the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) and the Protecting Access to Medicare Act of 2014 (PAMA) are 2 of the most consequential pieces of legislation impacting the pathology and laboratory industry in the last 20 years. Another current issue of far-reaching impact for pathologists is balance billing, and yet many pathologists have little or no understanding of balance billing. Pathologists at all stages of their careers, and in every professional setting, need to participate. Academic pathologists have a special obligation to, if not become directly involved in advocacy, at least have a broad and current understanding of those issues, as well as the need and responsibility of pathologists to actively engage in advocacy efforts to address them, in order to teach residents the place of advocacy, and its value, as an inseparable and indispensable component of their professional responsibilities.

The Basics of Managed Care and Its Impact on Private Practice

This chapter describes “managed care” insurance systems and practices that were created to manage healthcare costs. Effects on private mental health practice are identified, such as decreases in reimbursement, documentation requirements, treatment reviews, and other intrusions into clinician–client privacy and decision making. Potential advantages of participation are also identified. Key factors that private practitioners should take into account when deciding whether to participate with managed care organizations include careful contract reviews, likely credentialing requirements, and the impact of reimbursement on a practice. Potential solutions to common challenges are provided, such as limits on balance billing and waiver of co-payments. Ethical concerns specific to providing mental health treatment in the managed care context are discussed, such as limits on privacy and confidentiality. Potential implications of the ongoing seismic changes in the healthcare system for the future of managed care and private practitioners are explored.