AN overhaul of the decade-old case rate system of the Philippine Health Insurance Corporation (PhilHealth), and adoption of a Diagnosis-Related Groups (DRG) payment model may provide fairer financial coverage for both hospitals and patients, according to a study.
The recent study by state-run think tank Philippine Institute for Development Studies (PIDS) recommended that PhilHealth shift to a DRG model to align hospital reimbursements with the actual complexity and cost of patient care.
‘Payments based on DRGs are more realistic, offering better financial coverage for both providers and patients,’ the authors said.
The DRG payment model is an evidence-based system that classifies patients by diagnosis, severity and resource use to ensure that reimbursements match the actual complexity of care, according to PIDS.
Under this, hospitals would receive prospective payments based on expected service volume and performance through a Global Budget arrangement, as mandated by the Universal Health Care (UHC) Law, PIDS said.
Hospitals would receive frontloaded funding, or their portion of the overall health budget, at the beginning of the fiscal period rather than having to wait months for reimbursements.
Under the current All Case Rates system, hospitals would spend about 49 days preparing and filing claims after a patient’s discharge. It would then take PhilHealth another 31 days to process and pay the healthcare provider.
In 2023, it took a median of 87 days to process claims, while those returned for corrections averaged 221 days, from patient discharge to payment.
‘These delays can strain hospital cash flow, especially for smaller or provincial facilities, and affect their ability to sustain operations and maintain service quality,’ PIDS said.
The ACR system, the study found, has not kept pace with the increasing costs of healthcare in the country.
PhilHealth pays hospitals a fixed amount per illness or procedure, regardless of severity. However, of the 8,869 case rates, 99.9 percent of these have not been updated since 2013.
‘While PhilHealth’s nominal reimbursement has remained the same, its real peso value has declined, and hospital charges have continued to rise,’ the authors said.
For example, the case rate for a normal childbirth remains at P6,500 for years-worth only P3,900 in 2023 after accounting for inflation.
This has made it more challenging for hospitals, particularly public and provincial ones, to pay operating costs while maintaining services affordable for patients, the authors said.
Average hospital charges rose 51 percent between 2018 and 2023-from P23,852 to P36,130-while PhilHealth’s reimbursements remained at about P11,000.
The study found that hospitals are left to absorb the shortfall or pass on some expenses to patients since around 98.8 percent of hospital claims now exceed the case rate.
Even with insurance coverage, Filipinos remain financially vulnerable, as evidenced by out-of-pocket payments still comprising about 44 percent of total health spending.
‘When case rates do not consider clinical complexity, healthcare providers may face financial risk and incur losses while delivering the full range of services needed to treat complicated patient cases,’ the authors added.
The current setup, the authors warned, penalizes hospitals that care for more complex or multiple-condition patients and passes the financial burden to those already struggling with illness.