Timely Medical Audits Learning for Philippines

The Philippine Health Insurance Corporation (PhilHealth) had developed a health care provider performance assessment system around the same time that the JLN’s Medical Audits collaborative was launched in 2015. The new PhilHealth monitoring system was designed to enforce performance standards among health care providers across different regions of the country. While the policies, processes and systems were put in place, the monitoring and evaluation (to check if the intended objectives were being met), did not exist. The launch of the Medical Audits collaborative could not have been timelier for PhilHealth’s Standards and Monitoring Department.

A medical audit system is an iterative quality-improvement process that seeks to improve patient care and outcomes by systematically reviewing care against explicit criteria and the implementation of change.  At the time, for the Philippines this meant revisiting the control indicators and developing triggers to take action for audits to ensure cost containment and quality improvement.

JLN’s Medical Audits collaborative leveraged the experience of South Korea, a country with a mature health care system with an advanced provider performance and medical audit systems in place.  A mix of virtual learning through webinars, email exchanges and WhatsApp chats, enriched with a series of site visits to South Korea through 2016, allowed participating JLN member countries to learn from each other and receive first-hand exposure to the established medical audit system in South Korea.

The participating PhilHealth members shared their experiences and reviewed their performance indicators for quality of care, patient satisfaction, financial-risk protection and fraud detection. Based on findings from analytics on claims in the database, the team found that some claims for conditions, such as pneumonia, had a length of stay below the recommended standard, which affected the quality of health care provided. PhilHealth decided to incorporate recommended length of stay as a control indicator for the reimbursement of claims. PhilHealth is considering bringing back pre-payment medical review to catch these inconsistencies.

Further, a shift in PhilHealth’s payment system (to the bundled case payment from fee-for-service system) enhanced claims processing efficiency, but also compromised the rigor of the pre-payment medical review process. In some cases, the removal of some controls led to an unintended increase in benefit payouts. Insights from the experienced medical audit system of countries like South Korea allowed the Philippines’ participating team to contribute to the development of medical review criteria for the top ten paid claims, which strengthened the controls in the pre-payment review process.

Aside from honing monitoring, participation in the collaborative helped PhilHealth build the capacity of its staff and instill in them the importance of data quality. The participating members shared the knowledge from the collaborative with colleagues through seminars, raising awareness around the need for standardization and the use of indices to ensure that changes introduced in the system are determined by the use of thresholds.

PhilHealth is continuing its UHC journey, working with research and development partners to determine thresholds for triggers for fraud identification and explore the use of machine learning and/or artificial intelligence to identify unusual patterns. It is also looking forward to the final product of the collaborative, a toolkit on medical audits set to launch at the end of 2017, to use as an additional guide for monitoring provider performance in the Philippines.

“The Medical Audits collaborative was a collaborative in the truest sense of the term. It was an opportunity for us to share what works well in the Philippines and learn from other participating members. The experiences from other countries are contributing to improving our medical audits systems and monitoring activities.”

Gilda “Gitchi” Diaz
OIC-Vice President, Quality Assurance Group, PhilHealth, the Philippines

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