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Monitoring Payment to Contracted Hospital in Laos.

Monitoring Payment to Contracted Hospital in Laos. Social Security Organization, Luang Prabang, Lao P.D.R 24– 26 April , 2008. Outline. Overview Types of payment. Exclusion items Limitations (Constraints) of implementation. Future Plan payment to contracted hospitals. Overview.

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Monitoring Payment to Contracted Hospital in Laos.

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  1. Monitoring Payment to Contracted Hospital in Laos. Social Security Organization, Luang Prabang, Lao P.D.R 24– 26 April , 2008

  2. Outline • Overview • Types of payment. • Exclusion items • Limitations (Constraints) of implementation. • Future Plan payment to contracted hospitals.

  3. Overview Social Security Organization (SSO) has run its operations since June 2001

  4. Social Security system for enterprise employees in Laos. • Decree 207/PM on Social security system for Enterprise Employees. • This decree governs both short and long term benefits: • Short term benefits • Medical Care benefit -Sickness benefit • Maternity Benefit -Funeral benefit • Employment Injury • Long term benefits • -Invalidity benefit -Retirement Pension • Survivor benefit

  5. Data Structure and Workflow Child and spouse Name Surname Employees Workplace Name Employers Name of enterprise Family Book No. Date of birth Date of birth Occupation SSO Card ID Card Family Book No.

  6. Information Workflow

  7. Cycle of life A new family member declared and added Membership ends but family members still activate Dependent now beyond the SSO’s coverage or becomes a new member Information Adjusted and Updated Member status changed Opportunity to get new job or mission in other provinces

  8. Social Security Coverage Contact Medical Providers in province Subcontact Medical Providers in district Vientiane   Savannakhet Champasack Extended branches Planned extensions

  9. The implementation of Social Health Insurance in Laos. • Decree 207/PM on Social security system for Enterprise Employees. • According to the decree the coverage of beneficiaries is included insured person, spouse and children up to 18 years old and if continue study will be coved up to 25 years old. • - The first step covered children up to 6 years old, year 2001. • -The second step covered children up to 10 years old,2003. • -The third step covered children up to 18 years old, from 2005 until now.

  10. Types of payment to provider for SSO • Capitation • Risk Adjusted Capitation • High Cost Treatment

  11. Capitation • Costing study • Unit cost • Utilization rate • Pay per beneficiary • Monthly

  12. Risk Adjusted Capitation • SSO pays additional amount to hospitals Six chronic diseases covered including: • Hypertension • Diabetes • Hepatitis • Kidney failure (except hemodialysis) • Goiter • Cardiopathy

  13. Method of RACP to provider The steps are as follows: • Total points of 6 diseases from every hospital is divided by the total points of 6 diseases of each hospital. • The result is multiplied by the number of beneficiaries and by the amount of 3,500 kips. • Paid to providers every 3 months.

  14. High Cost Treatment • Neurosurgery(1,500,000kip) • Osteosynthesis(50%) • Transportation(50%) • Ct scan(50%)

  15. Exclusion items • There are 15 items as follows: 1.Sex interchange 2.Spectacles and artificial lenses except for work accident and occupational work 3.Artificial insemination in case of infertility 4.Prevention or treatment that is already covered by government

  16. Exclusion items (cont.) 5.Organ transplantation 6. Vasectomy and sterilization 7.Thalasemia 8.Hemodialysis 9.Aesthetic treatment 10.Open heart surgery 11.Motor Vehicles accident (non work related)

  17. Exclusion items (cont.) 12.Retro-virals drugs and Aids cocktails 13.In patient care is limited to 90 days per episode in one year 14.Dental care (except for extraction, pain relief) 15.Chemotherapy or Radiotherapy for malignant cancer (tumours).

  18. Limitation or constraints • Names of spouse and children not collected, no individual beneficiary records • Do not understand the importance of registration when changing their status. • Do not understand the regulations for medical care benefit • Forget SSO card and ID card when going to the hospital • Some employers recruit employees with their nick name, and • Some employees, when changing employer, do not inform SSO because they don’t know or forget and so receive 2 SSO ID cards.

  19. Limitations Identification and approve - Duplicated ID card

  20. - Not all have family books ΠIn the family book there is no photo of children, especially new born baby.

  21. Future plan of payment • ►For OPD pay using Capitation • ►For IPD pay using DRG • Before using DRG we need complete information from hospitals on cost of treatments for each disease and the costs of other fees charged by hospitals. Standard prices for drugs to be agreed by all hospitals.

  22. Thank you very much

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