The Philippine Health Insurance Corp. (PhilHealth) plans to partially adopt a diagnosis-related groups (DRG) payment model for selected diseases to test its efficiency in offering fairer case rates, an official said Friday.
PhilHealth corporate affairs group vice president Walter Bacareza told reporters the agency would select specific diseases for DRG implementation as part of a cautious, testing-based strategy.
“We will select some diseases for DRG,” Bacareza said, explaining the desire to avoid public missteps or system glitches.
This phased approach mirrors strategies used by other nations like Thailand and Japan, which began imposing the DRG system on a selected number of diseases rather than an immediate, total implementation.
Bacareza said the initial diseases could potentially be the country’s top 10 diseases, although the final strategic direction depends on an ongoing study by the agency and its partners.
The DRG model represents a shift from the current all case rates (ACR) system’s flat rates. It is an evidence-based system that identifies the appropriate reimbursement rate for patient care, factoring in social demographic details and the complexity of cases. This includes considering the patient’s age and possible complications that may accompany the illness.
PhilHealth asked private hospitals—Levels 1, 2, and 3—and infirmaries to participate in shadow billing. Stakeholders are called upon to submit their claim form 5 and electronic statement of account as soon as possible, as these documents will be used to compute the DRG rates.
PhilHealth said in a Nov. 6 advisory that shadow billing is necessary to “develop a case mix profile and initial PHL-DRG rates in preparation for implementation.”
The exercise will also allow PhilHealth to test and refine the IT system for claims submission, processing, and grouping that will be used for PHL-DRG.
The submission of these documents enables the agency to collect DRG data without disrupting the existing inpatient benefit payment under the ACR model and provides health facilities an early chance to prepare their own systems for DRG implementation, it said.
