BACKGROUND

PhilHealth serves as the Philippines’ national health insurance provider and is central to implementing the Universal Health Care (UHC) Law. Despite this, existing gaps and ongoing challenges in claims and financial management systems continue to affect public healthcare facilities’ operations and sustainability.

This article examined the effectiveness and challenges of PhilHealth’s claims and financial management systems in public healthcare facilities, focusing on accreditation, claims processing, reimbursements, and financial governance.

A qualitative multiple-case study design was employed in Quezon City and the provinces of La Union, Sorsogon, Leyte, and Bukidnon, with data collected from 2022 to 2023. Prior to data collection, a certificate of exemption was granted by the Department of Health – Single Joint Research Ethics Board (DOH-SJREB). Data were collected through key informant interviews with healthcare facility heads, claims processors, and PhilHealth personnel, supplemented by document reviews and facility observations. Thematic analysis was employed to examine the implementation of national health insurance policies at the facility level.

Accreditation standards are uniformly defined, yet compliance varies widely, directly influencing reimbursement outcomes. Facilities with compliance gaps often face provisional accreditation, downgrades, or suspension, resulting in reduced revenue. Although the Universal Health Care (UHC) Law guarantees patient access to PhilHealth benefits, the efficiency of claims processing remains uneven and highly dependent on administrative capacity, staffing adequacy, and digital infrastructure. Systemic inefficiencies at both PhilHealth and facility levels contribute to delays and claim denials. Reimbursements are further constrained by outdated case rate ceilings, inconsistent financial practices, inadequate recordkeeping, weak information systems, and poor storage conditions—particularly in lower-level hospitals and rural health units.

Reforms in claims processing workflows, information system integration, and financial management capacities are crucial to enhance reimbursement efficiency. Strengthening these systems is fundamental for supporting sustainable, equitable, and high-quality healthcare delivery in the public sector within the Universal Health Care (UHC) framework.

In recognition of the morbidity and mortality associated with human immunodeficiency virus (HIV), the Joint United Nations Programme on HIV/acquired immunodeficiency syndrome (AIDS) (UNAIDS) aims to end the epidemic by setting and striving to achieve the ambitious 95-95-95 targets. However, Singapore is still not performing well in the first UNAIDS target. The National HIV Programme (NHIVP) developed this set of recommendations based on an adaptation of major international guidelines from the World Health Organization and the US Centers for Disease Control and Prevention. The goals of this recommendation are: (1) to increase the uptake of HIV testing; (2) to allow earlier detection and identification of individuals with unrecognised HIV infection; (3) to facilitate linkage to clinical services; and (4) reduce further transmission of HIV infection in Singapore.
Humans ; Singapore/epidemiology* ; HIV Infections/epidemiology* ; United States ; HIV Testing ; Mass Screening ; World Health Organization ; Practice Guidelines as Topic ; Centers for Disease Control and Prevention, U.S. ; National Health Programs

Objective: This study aims to explore and analyze the modern contraceptive use of National Health Insurance (NHI) participants before and during the COVID-19 pandemic in South Kalimantan, Indonesia. Methods: This research is an ecological study using aggregated data from 13 Districts/Cities in South Kalimantan. This study used secondary data in 2018-2020 from the official website of the National Population and Family Planning Agency. Spatial analysis and paired T-test were used. Results: There were 30.7% of Districts/Cities in stagnation and 30.7% in the decline of modern contraception use during the pandemic (2019-2020). In addition, the study showed that there were differences in the use of modern contraception before (2019) and during the COVID-19 pandemic (2020) among active family planning acceptors of NHI participants (p=0.048). Conclusion The existence of NHI, especially recipients of contribution assistance, can increase the use of modern contraception in South Kalimantan. There are differences in the use of modern contraception before and during the COVID-19 pandemic among NHI participants.
National Health Programs ; National Health Insurance ; COVID-19

Objective. The study evaluates the clinical profile of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP), as well as time intervals between PZBP screening, approval, and timing of surgery. Methods. A review of medical records was done to collect data on time intervals between the screening process and Philhealth approval in CABG patients under PZBP. The clinical profile and surgical outcomes of patients were also evaluated. Results. Sixty-three patients were included from March 2017 to December 2018. Most patients were under 61-70 years old. Hypertension was the most commonly observed comorbidity. Time intervals were analyzed including identification for surgery to eligibility screening (2–217 days, median 25 days), Philhealth approval (8–266 days, median 20 days), and surgery (9-403 days, median 33 days). Postoperative atrial fibrillation was seen in 22.58%. The most commonly observed complication prolonging hospitalization was pneumonia. Conclusion. This is the first local study which evaluated the timelines of PZBP. Results may be use as basis of follow up study in the future for identification of an acceptable timeline intervals. Several modifiable factors affecting time intervals were identified for further improvement of healthcare services. The leading cause of increase length in hospitalization were HAP and AF.
Coronary Artery Disease ; Vascular Diseases ; Vascular Surgical Procedures ; National Health Programs

National Health Insurance Service (NHIS) database included approximately 5.5 million Korean enrollees > 60 years of age. A total of 588,147 participants were randomly selected for senior cohort using 10% simple random sampling. We identified senile (> 65 years old) patients who underwent hip fracture surgery from January 2005 to December 2014 and those who developed pneumonia during hospitalization from the NHIS-Senior cohort. The index date of hip fracture occurrence was defined as the date of admission to the acute care hospital. The last date of follow-up was defined as the date of death or 31 December 2015, whichever came first. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of pneumonia on all-cause mortality.RESULTS: During the enrollment period, a total of 14,736 patients, who were older than 65 years, underwent hip fracture surgeries. Among them, 1,629 patients (11.05%) developed pneumonia during the hospitalization. The pneumonia incidence was 16.39% (601/3,666) in men patients and 9.29% (1,028/10,042) in women patients. Compared to 13,107 non-pneumonia patients, adjusted relative risk (aRR) of death in pneumonia patients was 2.69 (95% confidence interval [CI], 2.14–3.38; P < 0.001) within postoperative 30-day, 3.40 (95% CI, 3.01–3.83; P < 0.001) within postoperative 90-day, 2.86 (95% CI, 2.61–3.15; P < 0.001) within postoperative 180-day and 2.31 (95% CI, 2.14–2.50; P < 0.001) within postoperative 1-year. According to patient's age, the aRR of death in pneumonia patients was 5.75 (95% CI, 2.89–11.43) in adults aged < 70 years, 5.14 (95% CI, 4.08–6.46) in those aged 70–79 years, 3.29 (95% CI, 2.81–3.86) in those aged 80–89 years and 2.02 (95% CI, 1.52–2.69) in those aged ≥ 90 years. The aRR was 3.63 (95% CI, 3.01–4.38) in men pneumonia patients, and 3.27 (95% CI, 2.80–3.83) in women pneumonia patients.CONCLUSION: The prevalence of pneumonia in elderly hip fracture patients was 11.05%. Men had higher incidence (16.39%) than women (9.29%). Compared to non-pneumonia patients, the pneumonia patients had higher 30-day to 1-year mortalities with aRR of 2.31 to 3.40. They had increased mortality in all age groups older than 65 years with aRR of 1.52 to 4.08. Both genders of pneumonia patients had higher risk of mortality (aRR, 3.63 in men and 3.27 in women) compared to non-pneumonia patients.]]>
Adult ; Aged ; Cohort Studies ; Female ; Follow-Up Studies ; Hip ; Hospitalization ; Humans ; Incidence ; Korea ; Male ; Mortality ; National Health Programs ; Pneumonia ; Prevalence ; Proportional Hazards Models

National Health Insurance Service-Senior Cohort database, we identified 39,519 people who participated in the National Screening Program for Transitional Ages at the age of 66 during 2007–2008. Impaired mobility was defined as taking 10 seconds or longer to perform the TUG test. Functional dependency occurrence was defined as the initiation of receiving national Long-Term Care Insurance services—home care or admission to long-term care facilities. Cox proportional hazard regression models were used to assess the hazard ratios (HRs) for dependency occurrence according to baseline TUG test results.RESULTS: The mean follow-up period was 5.7 years. Occurrence rates of dependency were 2.0 and 3.4 cases per 1,000 person-years in the normal and impaired TUG groups, respectively. Impaired mobility was associated with a higher risk of functional dependency occurrence (adjusted HR [aHR], 1.65; 95% confidence interval [CI], 1.40–1.95; P < 0.001). Additionally, in the subgroup analysis for the participants with intact baseline activities of daily living, impaired mobility was associated with a higher risk of dependency occurrence (aHR, 1.65; 95% CI, 1.33–2.04; P < 0.001).CONCLUSION: The TUG test might be a useful predictive marker of subsequent functional dependency occurrence. Intervention to prevent functional dependency may be helpful for older adults with impairment on the TUG test.]]>
Activities of Daily Living ; Adult ; Cohort Studies ; Follow-Up Studies ; Gait ; Geriatric Assessment ; Humans ; Insurance, Long-Term Care ; Long-Term Care ; Mass Screening ; National Health Programs

BACKGROUND AND OBJECTIVES: We aim to explore the additional discriminative accuracy of a deep learning (DL) algorithm using repeated-measures data for identifying people at high risk for cardiovascular disease (CVD), compared to Cox hazard regression.METHODS: Two CVD prediction models were developed from National Health Insurance Service-Health Screening Cohort (NHIS-HEALS): a Cox regression model and a DL model. Performance of each model was assessed in the internal and 2 external validation cohorts in Koreans (National Health Insurance Service-National Sample Cohort; NHIS-NSC) and in Europeans (Rotterdam Study). A total of 412,030 adults in the NHIS-HEALS; 178,875 adults in the NHIS-NSC; and the 4,296 adults in Rotterdam Study were included.RESULTS: Mean ages was 52 years (46% women) and there were 25,777 events (6.3%) in NHIS-HEALS during the follow-up. In internal validation, the DL approach demonstrated a C-statistic of 0.896 (95% confidence interval, 0.886–0.907) in men and 0.921 (0.908–0.934) in women and improved reclassification compared with Cox regression (net reclassification index [NRI], 24.8% in men, 29.0% in women). In external validation with NHIS-NSC, DL demonstrated a C-statistic of 0.868 (0.860–0.876) in men and 0.889 (0.876–0.898) in women, and improved reclassification compared with Cox regression (NRI, 24.9% in men, 26.2% in women). In external validation applied to the Rotterdam Study, DL demonstrated a C-statistic of 0.860 (0.824–0.897) in men and 0.867 (0.830–0.903) in women, and improved reclassification compared with Cox regression (NRI, 36.9% in men, 31.8% in women).CONCLUSIONS: A DL algorithm exhibited greater discriminative accuracy than Cox model approaches.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02931500
Adult ; Artificial Intelligence ; Cardiovascular Diseases ; Cohort Studies ; Female ; Follow-Up Studies ; Humans ; Insurance, Health ; Learning ; Male ; Mass Screening ; National Health Programs

The Big Data Research Committee of the Korean Society of Gastroenterology conducted activities and researches with three goals. First, it provides the basis for proper and cost-effective treatment of digestive diseases in Korea. Second, it carries out population-level global research by establishing a system of big data analysis related to gastroenterology. Third, it provides the members of the Korean Society of Gastroenterology with the opportunity to plan and assess the public interest related to big data. The studies published by the committee members in this paper were carried out under these objectives, and the findings are believed to have achieved the public interest goals that may be helpful in the current medical and health policy. The construction of the big data infrastructure for digestive drugs is also underway, and we expect to see meaningful results pertaining to important digestive drugs. Research using public health medical big data, such as the National Health Insurance Corporation data base, should ultimately provide a basis for reflecting public messages and policies for the public. To this end, it is necessary for Korean researchers to lead efforts to lower the barriers and to approach relevant information and opportunities using big data research.
Committee Membership ; Gastroenterology ; Health Policy ; Korea ; National Health Programs ; Public Health ; Statistics as Topic

BACKGROUND: Health policies in the Philippines have evolved in response to increasing health demands of older adults. However, there is a lack of research on equity among the ageing population in low-middle income countries. The objective of this study was to identify the trends in National Health Insurance Program (NHIP) coverage and healthcare utilization among older adults in the Philippines for the period from 2003 to 2017, during which NHIP expansion policies were implemented, focusing on reductions in socio-economic inequalities. METHODS: A literature search of policies for older adults and an analysis of four Philippine National Demographic and Health Surveys (2003, 2008, 2013, and 2017) with data from 25,217 older adults who were 60 years or older were performed. The major outcome variables were NHIP coverage, self-reported illness, outpatient healthcare utilization, and inpatient healthcare utilization. Inequalities in NHIP coverage and healthcare utilization according to wealth were evaluated by calculating the concentration index for individual years, followed by a regression-based decomposition analysis. RESULTS: NHIP coverage among older adults increased from 9.4 (2003) to 87.6% (2017). Although inequalities according to wealth quintile were observed in all four surveys (all P < 0.001), the concentration index declined from 0.3000 (2003) to 0.0247 (2017), showing reduced inequalities in NHIP coverage over time as observed for self-reported illness and healthcare utilization. NHIP coverage expansion for older adults in 2014 enabled equal opportunity for access to healthcare. CONCLUSION The passage of mandatory NHIP coverage for older Filipino adults in 2014 was followed by a reduction in inequality in NHIP coverage and healthcare utilization according to wealth.
Aged ; Aged, 80 and over ; Female ; Healthcare Disparities ; trends ; Humans ; Insurance Coverage ; trends ; Male ; Middle Aged ; National Health Programs ; legislation & jurisprudence ; statistics & numerical data ; Philippines ; Socioeconomic Factors

BACKGROUND: Statistical data of undiagnosed people living with human immunodeficiency virus (PLHIV) are of great importance to human immunodeficiency virus (HIV) infection control. This study estimated the total number of PLHIV using nationwide claims data.METHODS: This study used data of the incident HIV cases identified by the National Health Insurance System between 2009 and 2015. The number of patients with acquired immune deficiency syndrome (AIDS) was identified by diagnoses or prescription records. The estimated number of PLHIV and the time to diagnosis were calculated from the incident numbers of HIV and AIDS cases using the HIV Modeling Tool of the European Center for Disease Prevention and Control.RESULTS: Between 2009 and 2015, a total of 7,033 PLHIV and 2,899 AIDS patients were diagnosed. In 2009, the number of incident HIV cases was 873 (460 AIDS patients), increasing to 995 (337 AIDS patients) in 2015. Besides, the estimated number of prevalent cases was 10,753 in 2009, compared to 14,880 in 2015. Patients visiting health facilities accounted for 42.9% (4,616/10,753) in 2009 and 64.1% (9,544/14,880) in 2015. In 2009, there were 8,363 (77.8%) undiagnosed HIV cases, experiencing a decline to 6,215 (41.8%) in 2015. It took a mean of 6.96 years to diagnose after HIV infection.CONCLUSION: This study estimates the total burden of HIV infection in Korea for the first time using an internationally recognized HIV modeling tool. Claims data can be used to estimate the number of undiagnosed cases by identifying the total number of PLHIV and AIDS patients visiting health facilities.
Acquired Immunodeficiency Syndrome ; Diagnosis ; Health Facilities ; HIV Infections ; HIV ; Humans ; Infection Control ; Korea ; National Health Programs ; Prescriptions