Utilization of Inpatient Care in the Philippines: Evidence from Social Health Insurance Claims Data

Inequities in access to healthcare are pervasive in many low- and middle-income countries (LMICs), manifesting as large socio-economic gradients in healthcare utilization and, subsequently, disparities in population outcomes. LMICs also often confront inefficient health systems, partly due to under-investments in primary health care (PHC)—an approach that drains resources and worsens inequity. The Philippines is no exception to these issues. Previous research has demonstrated (1) significant disparities in health service utilization among the richest and poorest regions, and (2) a prevalence of potentially preventable hospital admissions due to ambulatory care sensitive conditions (ACSCs)—a key marker of health system efficiency. Hospitals and curative care account for a large portion of the country’s health expenditure, while out-of-pocket spending remains high. The Universal Health Care Act of 2019 presents an opportunity for the country to implement structural health system reform, beginning with efforts to establish health financing mechanisms that improve equity in access to health services and enhance health system efficiency. Given this, there is an urgent need for monitoring and evaluation systems to inform strategic purchasing. Large-scale and granular data are required to analyze utilization and provider performance to truly understand the magnitude of health system inequities and inefficiencies. To this end, using the Philippine Health Insurance Corporation inpatient eClaims dataset comprised of 86 million data points, this paper (1) analyzed inpatient care utilization and its associated costs, and (2) measured the burden of potentially preventable hospital admissions due to ACSCs. Overall, PhilHealth spends more on inpatient claims, and the number of inpatient claims has consistently increased. Certain geographic regions exhibit high inpatient care utilization, which may indicate high inpatient demand, while low utilization of inpatient care in other areas may signal systemic barriers in financial and physical accessibility to care. As reimbursements have decreased, hospital charges have significantly increased, diminishing the support value of PhilHealth; this has likely contributed to entrenched disparities in care utilization among the rich and poor. Furthermore, ACSCs account for about 33 percent of all hospital claims and approximately 35 percent of reimbursements, adding to the financial and health system strain that could potentially be mitigated with effective PHC. The proportion of ACSCs is generally higher in rural areas compared to urban areas, highlighting gaps in PHC systems. Measuring the utilization of inpatient services through large-scale and granular claims data presents an opportunity to inform strategic purchasing policies.