Risk Adjustment of Capitation Payment System: What Can Indonesia Adopt from other Countries? (original) (raw)
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The response of providers to capitation payment: a case-study from Thailand
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Those designing payment systems for health care in low and middle income countries are increasingly looking to capitation payment, in order to avoid the cost inflation experienced with fee-for-service payment. However, there is virtually no documentation of the experience of introducing capitation payment, or of its effects. This paper draws on several research studies to explore responses by health care providers at both the market and facility level to the introduction of capitation payment, in the context of a new compulsory insurance scheme for workers in Thailand. The paper ends by identifying lessons for both Thailand itself and for other countries.
PLOS global public health, 2024
Different provider payment systems generate different incentives for patients, providers, and purchasers. Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and has made reforms to its provider payment methods to create incentives in providers for cost containment. Starting with the fee for service method, it shifted to the Diagnostic Related Group (DRG) method in 2008 to improve cost containment. In 2012 the NHIS began piloting capitation method of payment which has been suspended since 2017 to allow for thorough review. This study uncovers the association between capitation payment system and patient health outcomes, utilization of healthcare services and referral patterns in Ghana based on data collected between November 2012 and January 2013. Using a cross-sectional data on 500 malaria patients who were enrollees of the NHIS from the two payment plans (i.e., capitation and DRG plan), ordered logit, negative binomial and logit regression results showed that patients under capitation were 11.9% less likely to report better health and had 1.583 fewer visits relative to patients under DRG. In relation to referrals, capitated providers were more likely to refer patients than under DRG plans. In the capitated region, better health outcomes were reported by patients of private health facilities. Capitation in Ghana was associated with under-provision of care, hence decreasing any efficiency gain from the reform. Implementors of capitation need to ensure a good monitoring and evaluation system for adequate provision of quantity and quality of care. Some limitations of this study include the use of cross sectional rather that panel data which follows individuals over time and therefore may be more able to provide definite information about cause-and-effect relationships. It also does not account for events before and after the introduction of any payment method. Overall, this study provides valuable information on the implementation policy for reintroducing capitation.
Approaches to capitation and risk adjustment in health care: an international survey
1999
This report is a survey of current capitation methods in health care finance in developed countries. It was commissioned as part of the fundamental review by UK Ministers of the formula used to allocate health care finance to local areas in England, being carried out under the auspices of the Advisory Committee on Resource Allocation (ACRA). The study was commissioned
THE EFFECT OF CAPITATION PAYMENT ON THE NATIONAL HEALTH
With the movement toward universal health coverage gaining momentum, the global health research community has made significant efforts to advance knowledge about the effect of various schemes to expand population coverage. The effect on efficiency, quality, and gaps in service utilization of reforms to provider payment methods are less well studied and understood.
Legal Description and Data Frame for Indonesia Finance Health Care Projection (PT. Askes, Indonesia
ABSTRAK Tujuan dari penelitian ini adalah untuk menganalisa performa dari Program Asuransi Kesehatan di Indonesia yang mengarah kepada efisiensi dan kesinambungan dari perencanaan program. Dimana, program tersebut telah memenuhi kebutuhan para anggotanya baik yang wajib maupun yang tidak wajib dari para pegawai negeri maupun non pegawai negeri. Mengingat begitu besarnya beban yang harus ditanggung oleh program dalam memenuhi kebutuhan jasa asuaransi kesehatan, maka program tersebut harus menyesuaikan antara biaya-biaya yang dikeluarkan oleh program tersebut maupun pendapatan yang berasal dari kontribusi peserta program dan subsidi pemerintah. Dalam penulisan ini, beberapa dokumnetasi, literature-literatur, interview, dan buku-buku manual digunakan. Selain itu beberapa standard inernasional seperti SNA 1993 (Social National Accounts 1993) dan Model Proyeksi Populasi dari United Nations dan ILO juga digunakan dalam penelitian ini. Hasilnya menunjukkan bahwa metode proyeksi yang digunakan selama 50 tahun kedepan mengindikasikan terjadi peningkatan pada jumlah anggota dan tertanggung yang pada akhirnya berpengaruh pada jumlah permintaan pada jasa asuransi kesehatan. Bagaimanapun, setelah tahun 1997 yaitu dengan dimulainya krisis ekonomi di Indonesia yang mempengaruhi menurunnya GDP, Negara-negara khususnya Indonesia telah mengubah pada cara-cara lama yang lebih menekankan pada ekspansi program kepada kualitas pelayanan, sehingga kesinambungan dan pengaruh biaya-biaya yang dikeluarkan telah menjadi suatu tantangan sekaligus menjadi suatu ancaman, yaitu mengenai kelanjutan dan kesinambungan bagi berjalannya program tersebut secara jangka panjang ABSTRACT The objective of this research was to analyze the performance of Social Health Insurance in Indonesia that applied to the efficiency and sustainability of the scheme. Whereas, it covered the compulsory and voluntary members from the public employee and all Indonesian people, therefore the program should be matched to the covered people as a beneficiary and cost of program on the one side to the income from the contribution on the other side. aurani I Santi
Lancet (London, England), 2018
As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care. We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results. In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3-8·8) to 71·7 years (71·0-72·3): the increase was 7·4 years (6·4-8·6) for ma...
Ghana Medical Journal, 2017
Objective: To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries. Methods: We did narrative review and synthesis of the literature on the effects of capitation payment on primary care. Results: Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship. Conclusion: The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care. Funding: Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352