Policy analysis on identifying copayment services for the shift in financing scheme of health care services

Hilton Y Lam; Ma-ann M Zarsuelo; Katrina Loren R Rey; Ma Esmeralda C Silva; Michael Antonio F Mendoza; Carmencita D Padilla

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Policy analysis on identifying copayment services for the shift in financing scheme of health care services

Author: Hilton Y. Lam ^{1
,

2} ; Ma-Ann M. Zarsuelo ^{1
,

2} ; Katrina Loren R. Rey ^{1
,

2} ; Ma. Esmeralda C. Silva ^{1
,

3} ; Michael Antonio F. Mendoza ^{1
,

4} ; Carmencita D. Padilla ⁵
Author Information

1. University of the Philippines Manila Health Policy Development Hub
2. Institute of Health Policy and Development Studies, National Institutes of Health, University of the Philippines Manila
3. College of Public Health, University of the Philippines Manila
4. College of Dentistry, University of the Philippines Manila
5. University of the Philippines Manila
Publication Type:Journal Article
Keywords: copayment
MeSH: Universal Health Insurance; Cost Sharing; Medical Overuse
From: Acta Medica Philippina 2020;54(6):701-709
CountryPhilippines
Language:English
Abstract: Background:As the Philippines moves toward universal health coverage, it is imperative to examine how to eliminate inefficiencies, particularly misuse, overutilization, and risks of fraudulent claims. This position statement aimed to identify health services requiring copayments for cost-efficient health financing for the Universal Health Care Act.
Methods:A qualitative study was employed using a systematic review of literature, and thematic analysis of policy roundtable discussion (RTD) was conducted. The systematic review of literature generated evidence for the policy brief and critical points for discussion in the stakeholders’ RTD forum. The RTD was organized by the UP Manila Health Policy Development Hub (UPM HPDH) with the Department of Health (DOH) and was participated by key stakeholders of the policy issue to attain consensus recommendations and develop criteria for identifying services requiring copayments.
Results:An algorithm is proposed by the UPM HPDH based on collective expertise as a guide for policymakers to assess each benefit package in terms of overutilization, the danger of depleting government funds, and the risk of fraud. The use of clinical pathways is suggested to assess the misuse and overutilization of health services. In addition to copayments, benefits packages prone to fraudulent activities should be subjected to fraud prevention processes. Copayment should be linked inversely to the preventability level of the disease or condition.
Conclusion:There were gaps in the current policies to identify services requiring copayment services. Copayment schemes should be carefully determined to prevent misuse, overuse, and fraud of appropriate and necessary health services, while at the same time not limit access to needed care.
Full text:2599-Article Text-14182-1-10-20201226.pdf