Monitoring Payment to Contracted Hospital in Laos'

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

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

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Overview

• Social Security Organization (SSO) has run its
  operations since June 2001

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• 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

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Data Structure and Workflow
Child and spouse
Name
Surname
Employees
Name
Workplace
Employers
Name of enterprise
Family Book No.
Date of birth
Date of birth
Occupation
SSO Card
ID Card
Family Book No.
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Information Workflow
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Cycle of life
A new family member declared and added
Membership ends but family members still activate
Dependent now beyond the SSOs coverage or
becomes a new member
Information Adjusted and Updated
Opportunity to get new job or mission in other
provinces
Member status changed
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Social Security Coverage
Contact Medical Providers in province
Subcontact Medical Providers in district
Vientiane
?
?
Savannakhet
Champasack
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• 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.

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Types of payment to provider for SSO

• Capitation
• Risk Adjusted Capitation
• High Cost Treatment

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Capitation

• Costing study
• Unit cost
• Utilization rate
• Pay per beneficiary
• Monthly

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Risk Adjusted Capitation

• SSO pays additional amount to hospitals
• Six chronic diseases covered including
• Hypertension
• Diabetes
• Hepatitis
• Kidney failure (except hemodialysis)
• Goiter
• Cardiopathy

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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.

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High Cost Treatment

• Neurosurgery(1,500,000kip)
• Osteosynthesis(50)
• Transportation(50)
• Ct scan(50)

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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

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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)

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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).

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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 dont know or forget and
  so receive 2 SSO ID cards.

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Limitations
Identification and approve

- Duplicated ID card

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- Not all have family books

In the family book there is no photo of
children, especially new born baby.
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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.

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Thank you very much