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Joko MulyantoDept. of Public Health and Community MedicineFaculty of MedicineJenderal Soedirman University

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Denition of payment system.!b"ective of payment system.

#asic concept of payment system.$ype of payment system.Capitation

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Mechanisms used to %pay& medicalcare providers'or(ani)ations forservices rendered to their clients

Ma"or approaches to payment ofhealth providers*

Direct payment by the patient.Direct payment by the patient+ later

reimbursement by ,rdparty payers.Direct payment by the ,rdparty payers+

patient bearin( no or only limited char(e.

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Set the ri(ht incentives for providersto provide su-cient+ hi(h uality

health services.Containin( the cost.

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Fi/ed and variable system0etrospective and prospective

systemUnit of reimbursement$ype of providers

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Fi/ed systemo 0eimbursement amount does not

chan(e as activities increase ordecrease.

o 1ot remunerated for the production ofe/tra unit.

o 0eceives lump sum+ e/ ante+ notrelated to the production.

o 2/ample* capitation+ salary.

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3ariable systemo 4ncremental income 5 m6re

production of e/tra unit.o May cause over production.o 2/ample * Fee for service

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0etrospective.Provider&s cost reimbursed e/ post.

Prospective.Provider&s payment rates or bud(etsare determined e/ ante.

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Per item7of7servicePer patient7day

Per casePer patientPer period

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PhysicianHospital

Pharmaceutical!thers+ i.e * public health services

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Fee for serviceSalary

CapitationPer diemCase payment8ine item bud(et9lobal bud(et

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FFS payment reimburse provider fordeliverin( specic items such asdoctor consultation+ sur(ical operation.

Divided into three sub(roups*7 !pen7ended fee.7 1e(otiated fee.

7 0e(ulated fee.Commonly used to pay physician

:outpatient care;.

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Supply induced demand.!ver treatment.

2

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Fi/ed amount of money for /edamount of time.

Can be set by ne(otiation.Can be ad"usted by a(e+ specialty+settin(+ responsibilities of doctor.

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Under treatment.=Patient shiftin(>

9ood cost control1eed to monitor performance+uality+ and access.

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!ne payment for one person+ for somebundle of services+ durin( a /edperiod of time+ re(ardless the actualnumber of services provided to eachperson.

Per member per month :PMPM;.

Can be full :t6tal; or partial capitation.Can be /ed or risk7ad"usted.$ransfer the nancial risk from ,rdparty

payers to the providers.

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Under treatCost shiftin(

4ncentive for promotion andpreventionPatient dumpin(Cream skimmin(

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Fi/ed amount for each inpatient dayre(ardless the actual use of service+

dru(s+ and medical products.Use for inpatient care :hospital;.$otal bud(et of hospital in a year$otal number of hospital inpatient

day in a year

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4ncrease len(th of stay and numberof admission.

0educe the intensity of care for eachhospital day.

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4nclusive /ed amount per case:usually per dia(nosis;+ re(ardless of

service and procedures provided.Usually use for inpatient care.2/ample* Dia(nostic 0elated 9roups

:D09&s;.Can be sin(le ?at rate per case+ or

can be risk ad"usted rate.

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0educe unnecessary services andlen(th of stay.

Up7codin( and cost shiftin(Unnecessary readmission.Under treatment+ early dischar(e.

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Provider is paid an amount per (ivenperiod :usually a year; for a dened

responsibility of service provisions.$he total amount is broken do@n intoitems such as salary+ dru(+euipment+ etc.

Usually applied in publicinfrastructure.

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Stron( administrative control 4n?e/ible

4ne-cient

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=one line> item bud(et for facilities for/ed period of time for speciedpopulation or service use.

Usually use for hospital.Soft (lobal bud(et vs. Hard (lobal

bud(et.Calculation based on*

7 4nput7 Historical spendin( and activities7 3olume of service and type of case

:case7mi/;.

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Fle/ibleContainin( cost

0educe access and lo@er ualityA

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$here is no =sin(le7best method>Combined methods is necessary to

(ive the ri(ht incentives for providerin order to provide adeuate andhi(h uality services.

Payment system consideration*

access :euity;+ e-ciency+ anduality.

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B"kmulyanto