Can Expanded Health Insurance and Improved Quality Protect Against Out-of-Pocket Payments?

Transcription

1 Can Expanded Health Insurance and Improved Quality Protect Against Out-of-Pocket Payments? Experimental Evidence from the Philippines SA. Quimbo University of the Philippines School of Economics N Wagner International Institute of Social Studies of Erasmus University Rotterdam ADB and 3ie s Conference on Making Impact Evaluation Matter: Better Evidence for Effective Policies and Programs Session 16: Health Insurance 4 September to 12.30, Auditorium C Asian Development Bank, Manila

2 Motivation Out of pocket payments continue to be the dominant source of financing for health care in many developing countries Results in poverty (van Doorslaer et al. 2006, Xu et al., 2007) Causes loss of productive assets (Sauerborn et al.1996) Increases debts and depletes savings (Sparrow et al. 2013)

3 Motivation We ask whether expanded health insurance and improved quality of care can reduce out-of-pocket payments Health insurance: directly reduces the hospital bill/ provides transfers conditioned on use of health care Improved quality of care: reduces the cost of health care

4 Related Literature Indonesia s Health Insurance for the Poor (Askeskin) program: Increased access to health, but at the cost of higher out-of-pocket spending for the insured who live in urban areas (Sparrow et al., 2013) Rural China s New Cooperative Medical Scheme: No reduction of out-of-pocket payments but rather an increase in some cases (Lei and Lin, 2009; Liu and Tsegai, 2011; Wagstaff et al., 2009; Zhou et al., 2009)

5 QIDS Experiment: An RCT in the Philippines Quality Improvement Demonstration Study ( ) 30 district/public hospitals in 11 provinces in the the central regions of the Philippines (the Visayas group of islands) Matched block design: 10 matched blocks of three hospitals Each matched block was located in a province Within each matched block, 2 interventions plus control were randomized Target beneficiaries of the interventions: children under 5 y.o. Funding from the US National Institutes for Health

6 Policy Platform Philippine Health Insurance Corporation (PhilHealth) Implemented both policy interventions with the Department of Health and 30 provincial governments as partners Mandate: universal coverage Provides insurance for most inpatient care (and some outpatient care) First peso coverage (benefit payments are subject to inner and outer ceilings that vary by case); reimbursement rates are about 36 percent Pays doctors in public hospitals a fixed peso amount per patient per day

7 ABCs of QIDS A = ACCESS B = BONUS C = CONTROL Expanded insurance benefits + zero copayment for children 5 years and under Bonus payments tied to quality scores Business-as-usual Policy Navigators Quality Monitoring through: - Clinical practice vignettes - Patient satisfaction surveys - Case load monitoring

8 Quality Measure in Bonus sites 70% vignette scores Clinical practice vignettes administered to physicians: paper cases, followed by questions on history taking, physical examination, ordering tests, diagnosis, treatment Pediatric cases of pneumonia, diarrhea, and dermatitis 20% case load 10% patient satisfaction

9 QIDS Vignettes Continues on the next page with more information

10 Some Related QIDS Findings, Further Questions on Pathways QIDS Intervention A: Expanded Health Insurance Reduced OOP? Increased Spending for Food? Increased Spending for Other Health Goods? Reduced Wasting (Quimbo et al. 2011)

11 Some Related QIDS Findings, Further Questions on Pathways Reduced Costs (Peabody et al. 2011) QIDS Intervention B: Bonus Payments for Improved Quality Reduced OOP? Increased Spending for Food? Increased Spending for Other Health Goods? Reduced Wasting (Peabody et al. 2013)

12 Balancing Tests

13 Descriptive Statistics (Outcome Variables, Round 2)

14 Results +/*/** indicates significance at the 10/5/1 percent level, respectively

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18 Summary of Findings Expanded health insurance and bonus payments for improved quality: Reduce out-of-pocket payments by percent Reduce spending outside the hospital by percent, which arguably increases hospital accountability over health outcomes Pathways for improved health Reduced out-of-pocket payments -> increased spending on health goods that prevent infectious diseases, namely, water, sanitation, and toiletry articles (by percent)

19 Policy Implications Health insurance and improved quality can protect households from impoverishing health spending Expenditure re-allocation from curative care to preventive care Supply-side interventions (provider payments-forperformance) is as effective in reducing out-ofpocket payments as demand side interventions (health insurance)