Health Insurance Handbook
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Important Considerations The methods by which health care providers are selected, engaged, and paid are key to the efficiency of the system as a whole. Health Insurance Goals
All payment methods create incentives for providers that affect their behavior. The first step in deciding how to select and pay service providers is to review the policy goals of a health insurance scheme—access, quality, revenue, efficiency, administrative simplicity—and select the provider payment method(s) that create incentives that are consistent with scheme goals. For example, if a goal of the health insurance scheme is to increase use of primary health care services, then you may choose to pay providers on a fee-forservice basis for primary health care and use strict global budgets for hospitals. It is important to anticipate how you will evaluate the effects of the selected payment method (see Element 8) so that you can make changes as needed. Current Service Delivery Market
Provider selection is an important design issue for health insurance because provider behavior is a major determinant of beneficiary satisfaction, as well as medical costs. A country should begin by reviewing the current market structure among health service providers, especially in relation to the target population and the benefits package. Issues to be considered include: Where are people going for services—public or private facilities? What are the cost and quality differences for service provision in the public versus private sector? What is the geographic distribution of providers (public and private)? What is the population’s perception of public and private providers? Policy makers should review the following information on providers to determine if the benefits package is feasible, decide how to select providers to maximize access by target beneficiaries, determine how to pay the providers and how providers at different levels will be linked (referral system), and identify possible efficiencies that can be realized through be er provider payment (e.g., downsizing empty hospitals).
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How are providers organized (individual practitioners, networking, institutional providers, and referral systems)? Where are they located, especially relative to target populations? What are the main types of health facility ownership (public, religious, NGO, private for-profit, cooperative)? What are the most common types and sizes of facilities (single private practice, group practice, network, clinic, hospital)? At what level of care do different types of service providers operate (primary, secondary, tertiary)? To what degree are services integrated? (single services, general health care services, vertical programs)? What is the reputation of different health care providers? How are they perceived by consumers?
Data on the following characteristics are often scarce, but extremely useful if available: