Researchers from the University of the Philippines Manila reviewed the implementation of  the All Case Rates (ACR) policy by the Philippine Health Insurance Corporation (PhilHealth) in  their study entitled, “All Case Rates Policy: Assessment and Evaluation of Policy Goals.” The  project was conducted last April 2021 to October 2022 and was commissioned by PhilHealth  and the Department of Science and Technology-Philippine Council for Health Research and  Development (DOST-PCHRD). 

The research team, led by Dr. Fernando B. Garcia, Jr., Dean of the University of the Philippines  College of Public Health, and Dr. Katherine Ann V. Reyes, made use of a mixed-method  approach in their investigation. Quantitative data was acquired from the ACR claims data,  PhilHealth statistics, and charts data covering the period of 2013 to 2020. Qualitative data  was also collected through Key Informant Interviews with 23 respondents from the PhilHealth  central and regional offices, healthcare institutions, and health financing experts to share  their insights on how the ACR is currently being implemented. 

From FFS to ACR and UHC 

PhilHealth initiated the ACR in 2013 to replace the previous fee-for-service (FFS) provider  payment mechanism (PPM) where healthcare providers and institutions are paid according  to each service provided to a patient. Under the ACR, PhilHealth pays inpatient care through a case-based provider payment mechanism.  The shift from FFS to case-based payment was intended to make payments operationally efficient and standardize the  delivery of quality healthcare services. 

The promulgation of the Universal Health Care Law in 2019, increased the momentum for  implementing health financing reforms. The UHC Law has mandated PhilHealth to make  critical policy changes to expand financial risk protection, especially for the most vulnerable  sectors of society. In response, PhilHealth commissioned the study to evaluate the  performance of ACR in meeting the policy goals of the Law and to develop recommendations  for future reforms. 

Designing a more beneficial PPM for Filipinos 

With the UHC expanding PhilHealth membership to cover the entire Filipino population, the  study recommends that PhilHealth refines its membership enlistment systems by  collaborating with the Philippine Statistics Authority (PSA). Strengthened information  technology (IT) infrastructures will also be necessary for efficient data management between  the PhilHealth and PSA. 

Streamlining claims processes and standardizing these processes across regions will also be  necessary to improve the turnaround time of reimbursements to healthcare institutions. 

Developing auditing guidelines with the Commission on Audit (COA) is also essential to  support this improvement. Researchers also found that there is a need to develop rules on  costing and timely updating of payment rates. While charges for indigents have been  eliminated or minimized through the various policies implemented by PhilHealth, it is  recommended to adjust the reimbursement rates of the ACR to improve financial coverage  to the average households. Revising case  rates or the fixed amount of reimbursements for specific illnesses, as well as diagnosis  selection rules, will also increase benefits for members. 

These findings are valuable in refining the systems and rules on the current implementation  of ACR, in order for the policy to further benefit Filipinos. 

“Research is definitely a crucial part of building health care systems that truly address the  health needs of the Filipino,” said DOST-PCHRD Executive Director Jaime Montoya. “With the  implementation of the UHC, it is important to further research efforts that will help us ensure  that our healthcare programs will maximize benefits for Filipinos and support the goals of  UHC,” he added. 

The study was presented to PhilHealth program managers and senior officials during the  annual 6th PhilHealth STUDIES Forum last November 2022. Its results and recommendations  will be used to inform future policies and reforms as UHC further matures in the country. The  study was monitored by the DOST-PCHRD, with funding from PhilHealth, through the  PhilHealth Supporting the Thrust for UHC through Data, Information, and Knowledge Exchange Systems (STUDIES) project.