Survey Results
A total of 43 neurosurgeons—29 (67%) from Indonesia and 14 (33%) from the Philippines—had valid responses to the survey. Majority of respondents (31.8%) cited malignant intracranial tumors as the neurosurgical condition that causes the worst economic hardship among patients and their families, followed by traumatic brain injury (27.3%), spinal trauma and spinal cord injury (15.9%), and aneurysmal subarachnoid hemorrhage (15.9%). See Fig. 1 below.
In terms of out-of-pocket (OOP) expenses for these conditions, malignant intracranial tumors were reported to impose the highest OOP expenses (43.2%), followed by emergency vascular diseases (38.6%), traumatic brain injury (34.1%), and degenerative spine disorders (34.1%).
Among the neurosurgical conditions needing greater financial subsidy, traumatic brain injury (27.3%) needed the most, followed by malignant intracranial tumors (18.2%), aneurysmal subarachnoid hemorrhage (15.9%), and spinal trauma and spinal cord injury (13.6%). See Fig. 2 below.
Socioeconomic Context of Neurosurgical Care
Few studies have examined the association between patient-level socioeconomic factors and outcomes across the various diseases that are treated by the specialty of neurosurgery—pediatric hydrocephalus (6, 7, 8), craniosynostosis (9), intracranial tumors (10, 11, 12, 13), aneurysmal subarachnoid hemorrhage (14, 15) and stroke (16, 17), traumatic brain injury (18, 19), spine disorders (20) and spinal cord injury (21, 22). Many of these studies describe the more frequently unfavorable outcomes among the inadequately insured and those with lower socioeconomic status. Due to the inherently costly nature of neurosurgical interventions, many of the socioeconomically disadvantaged patients seek the necessary care from public hospitals (4, 5). Whereas such public neurosurgical centers in Indonesia and the Philippines are mandated by legislation and government regulation to provide healthcare at minimum or zero cost, the reality is that many patients still incur out-of-pocket expenses (23, 24). These expenses are often catastrophic and push their families into impoverishment. Financial catastrophe from accessing surgery remains prevalent in LMICs, and most of those exposed to such financial risk live in sub-Saharan Africa and Southeast Asia (1).
Supply and Demand Sides of Neurosurgical Care
There are many reasons for the still prevalent out-of-pocket expenses in LMICs particularly in Indonesia and the Philippines. From the demand side of the healthcare system—the patients—both medical and non-medical costs account for the financial catastrophe suffered by poor patients following hospitalization and surgical operation (2). Surgical conditions are also known to result in a greater household poverty effect relative to other health problems and diseases (25). Poverty plays a role in reducing the affordability of transportation costs and caregiving expenses, while prolonged hospitalization results in income regression, unemployment, and opportunity costs for both the patient and the caregiver. The sociocultural disadvantage of lower levels of education among the poorer patients contributes to the more advanced presentation of disease at the time of first consultation. Inadequate health insurance also contributes to hesitancy in timely health-seeking behavior—a problem that poses a disadvantage to patients’ outcomes after treatment as well as their prognosis. Furthermore, it does not help that any neurosurgical intervention, or any surgical treatment for that matter, is perceived to be costly and expensive (1).
From the supply side of the health system—the healthcare providers—publicly-funded hospitals generally provide the needed wide range of emergency and elective neurosurgical care for poor patients. These hospitals are primarily financed from taxation and are appropriated a yearly budget from the national government through the Department or Ministry of Health, or from local or state-run universities. Many public hospitals do not have the bare minimum neurosurgical implements, surgical intensive care units, and even a computed tomography scanner. These complicate the usual treatment pathway for a neurosurgical patient—turning it into a cumbersome navigation around a generally disjointed referral network of hospitals (4, 5, 26). Despite the finite resources that beset government-financed hospitals, neurosurgical care provision in most centers has been largely sustained by the presence of an academic neurosurgical training program. The few hospitals with neurosurgical residency programs in Indonesia and the Philippines are generally better equipped to handle the more complicated and full range of neurosurgical diseases and conditions (27). And yet, like many of the public hospitals in low-resource settings, the efficiency of care is hampered by bureaucratic processes and protocols (1). Commonplace problems like the breakdown of equipment can take time to repair. The purchase of new equipment often gets encumbered in elaborate procurement processes (28). In these respects, the financing of purchasing and patient management can have an important impact on the quality and efficiency of neurosurgical care.
Health Financing: An Important Health Systems Function
Broadly, health financing comprises the mechanisms by which money is mobilized to fund and pay for health-sector activities, and how the funds are raised, used, and paid out to achieve health-related outputs (29). Financing and payment arrangements determine how much money is available or paid out, who bears the financial burden, who controls the funds, whether healthcare costs are controlled, and which groups or actors are given the incentive (30). A chief method of health financing is by way of health insurance. The organization of funds and the pooling of risks are the foremost functions of a health insurance scheme. Many countries, including both Indonesia and the Philippines, have some form of social health insurance (SHI) that is overseen or managed by the government. Health financing, in a pragmatic sense, is also a matter of policy. These policies and regulations create powerful incentives that influence the actions of individuals and organizations in a given healthcare system.
Socioeconomically disadvantaged patients who seek healthcare services are often price-sensitive. The out-of-pocket expenses they bear affect the volume and timeliness of healthcare they use, which in turn influences their overall health outcomes (29). As far as their healthcare utilization is concerned, the reach of social health insurance coverage in public hospitals is therefore paramount. Universal health coverage and a high degree of responsiveness in curbing out-of-pocket expenses on the part of SHI can improve the accessibility of surgical services, including that of neurosurgery.
Expanded Functions for Social Health Insurance
SHI at the national level acts as a payer for health care goods and services in a country. The Badan Penyelenggara Jaminan Sosial Kesehatan (BPJSK) is the single SHI agency in Indonesia while its counterpart is the Philippine Health Insurance Corporation (PHIC) in the Philippines (23, 24). In the face of limited resources in the public health sectors of Indonesia and the Philippines, SHI agencies have to do “strategic purchasing”—essentially to be cost-conscious and efficient in their payment of services from healthcare providers. Financial incentives or other mechanisms can motivate surgical providers to improve quality and efficiency of care, or to respond to increased patient demand. Similarly, poor patients respond to cost savings in the treatment of their illnesses. SHI agencies can certainly play a role in providing incentives—in the form of conditional cash transfers, for example—for improving intermediate indicators of treatment success as well as clinically important outcomes. See Fig. 3 below for the framework describing the important role of SHI in influencing the demand and supply sides of healthcare.
Potential Health Financing Solutions
Supply-Side Financing: Strategic Purchasing of Neurosurgical Services
Ideally, the role of SHI is to ensure that adequate resources are mobilized to meet the service entitlements of insured patients—ideally the whole population—and thus achieve “universal health coverage.” While financial risk pooling is an important function of SHIs in terms of equity considerations and financial risk protection for the insured, the added function of strategic purchasing can drive quality and efficiency of healthcare provision (1, 29, 31). Certain strategic purchasing methods can modify healthcare providers’ behaviors in their treatment decisions and ultimately influence the quantity, quality, and efficiency of neurosurgical care for example. The choice of which disease condition to subsidize is a matter of policy and executive decision, but is mostly founded on data on the costs of treatment, the burden of the disease, and the cost-effectiveness of interventions (32). Assuming the role of strategic purchaser, the SHI agency selectively enters into a contract with neurosurgical care providers. Providers in this sense would mean the hospital or institution including the neurosurgeons and allied health professionals. The purchaser and the provider then agree on a provider payment method for a standard treatment regimen.
Consider for example—traumatic brain injury (TBI)—for which the current standards of neurosurgical management are entrenched in universally accepted clinical practice guidelines (33). The prehospital management of a brain-injured patient is time-critical. While the workforce consideration of a low neurosurgeon-to-population ratio remains a perennial problem in Indonesia and the Philippines (27), the situation is exacerbated by financial considerations whereby a poor TBI patient often gets rushed to the emergency department of a much farther public hospital despite the proximity of a private hospital with neurosurgical services at the time of injury. This adverse selection by private hospitals presents an added disadvantage for an already economically disadvantaged patient who suffers from TBI, and whose clinical outcome could have been better were it not for a delayed neurosurgical treatment.
Conceptually, strategic purchasing allows buying of health services for certain groups of patients and uses financial levers and payment schemes that influence the behavior of providers including hospitals and neurosurgeons (32, 34). As the results of our survey in this study indicate, TBI is thought to require greater financial subsidies, similarly found in other studies (18, 19, 35). The case for subsidizing the full costs of treatment for patients with TBI is also justified by its cost-effectiveness (36). Strategic purchasing can realize this through contractual arrangements that would link attractive payment mechanisms to the goal of broadened access to emergency neurosurgical care for TBI patients who are brought to a nearest facility that happens to be a private, for-profit hospital. A catastrophic illness benefit package may be formulated by both the BPJSK and PHIC that would elevate the financial incentive for all neurosurgical providers to accept and manage TBI patients regardless of socioeconomic status (37, 38). Greater acceptability of this mechanism by neurosurgical providers are afforded by strategic purchasing because costing and payment schedules are negotiated and prearranged in collaboration with the providers themselves. The payments from the SHI agency to neurosurgical providers can be further complemented by an element of pay for performance (29), with a proportion of the fixed payment withheld and paid according to patient outcomes assessment and even other indicators such as timeliness of the surgical operation. In this way, the goal of quality and greater access to care can be achieved for the neurosurgical management of patients with TBI.
A prospective payment scheme brought about by strategic purchasing can also enable the pooling of paid-out funds on the part of provider hospitals to accrue future savings (32). The increased generation of revenue at the level of the hospitals can result in upfront investments that will finance the capital outlay costs for scaling up infrastructure and equipment needs, e.g., expansion of neurosurgical bed capacity, addition of dedicated neurosurgical operating theaters, or procurement of costly neurosurgical equipment. In this manner, the improved capacity of the provider hospital can increase neurosurgical volume and again, the goals of quality and better access to neurosurgical care can be achieved. In Table 1 below, we summarize other examples of strategic purchaser-provider arrangements.
Table 1
Purchaser-Provider Contractual Management for Health Financing.
Strategic purchasing functions*: | Examples for neurosurgery: |
1.Providing an appropriate range of services and locations relative to the distribution of the population by means of effective gatekeeping and referral | • Assignment of tiered neurosurgical centers (e.g., higher level and lower level) with a predefined catchment population based on geography and complexity of disease condition • Creation of centers of excellence for certain neurosurgical disease conditions based on available expertise of subspecialist neurosurgeons |
2.Selecting providers for accreditation | • Designating and credentialing private hospitals that are capable of accepting and managing traumatic brain injury and emergency neurovascular diseases • Selective contracting and progressive policy of deliberated reimbursement of expenses by accredited private hospitals that are incurred during emergency operations for indigent patients with traumatic brain injury and stroke |
3.Implementing provider payment methods efficiently, as in a prospective payment system | • Creation of a catastrophic illness benefit package for traumatic brain injury and/or malignant intracranial tumors • Capitation funding for every indigent patient who gets admitted in a private hospital on an emergency basis and needs life-saving neurosurgical intervention |
4.Making use of monopsonistic purchasing power | • Public-private partnership and debt financing for the capital outlay of infrastructure projects • Economies of scale purchasing arrangements for neurosurgical consumable implements |
5.Introducing generic essential drugs, devices, or implants lists | • Creation of a medicines access program for disease-altering drugs, e.g. temozolamide for patients with gliomas • Consignment and purchasing arrangements for steady supply of cranial and spinal implants and instrumentation |
6.Monitoring provider performance in terms of quality and efficiency | • Establishing a prospective database of outcomes report following surgery and adjuvant chemoradiotherapy for patients with gliomas • Merit-based payment and reimbursement of neurosurgical centers based on volume-outcome relationships, e.g. high-volume centers doing > 10 intracranial aneurysms per year will have seamless financing for purchase of aneurysm clips |
7.Ensuring mutual accountability between purchasers and providers through timely payments to healthcare providers and appropriate audit systems | • Checks and balances system that would minimize fraud and pilferage of payments and reimbursements, e.g. repeated neuroimaging of neurosurgical patients will have to be easily cross-checked through linkage with information technology systems • Strict penalty system for breach in contracts when it comes to timeliness of reimbursements, especially for time-critical and life-threatening neurosurgical operations |
*Adapted from: Trisnantoro L, Hendrartini J, Susilowati T, Miranti PAD, Aristianti V. Chapter 3: A critical analysis of selected healthcare purchasing mechanisms in Indonesia. In: Honda A, McIntyre D, Hanson K, Tangcharoensathien V. ed. by. Strategic Purchasing in China, Indonesia, and the Philippines (Comparative Country Studies, Vol. 2 No. 1 2016). Geneva: World Health Organization; 2016. p. 124. |
Demand-Side Financing: Conditional Cash Transfers for Neurosurgical Patients
Neurosurgical patients, herein considered the demand side of healthcare provision, constitute an important stakeholder as well in terms of health financing. Despite the fact that surgery in public hospitals is completely subsidized by the BPJSK in Indonesia and the PHIC in the Philippines—at little to zero cost for indigent patients—there remain substantial financial barriers (32). Frequently, financial catastrophe comes from non-medical costs of care such as the cost of transportation and living expenses of the caregiver (1, 2). For socioeconomically disadvantaged patients in the Philippines, even in-person outpatient follow-up after neurosurgery entails catastrophic expenses and may cause adverse life events that can negatively impact health-seeking behavior overall (39).
The results of our survey show that out-of-pocket expenses surrounding the management of those with malignant intracranial tumors are a prevalent form of health financing in Indonesia and the Philippines. For majority of patients with brain cancer in Indonesia and the Philippines, the standard Stupp protocol for the treatment of glioblastoma could bankrupt their families—often resulting in the patient never receiving or completing the disease-altering adjuvant chemotherapy and radiotherapy. Because adjuvant chemotherapy for glioblastoma is carried out on an outpatient basis—consultations at the oncology clinic during the course of the patient’s ongoing intake of oral drugs (temozolamide)—SHIs especially PHIC are currently not fully responsive in the aspect of financing. The responsibility of payment for the adjuvant treatments is frequently left to the hospital’s social welfare division or external charitable organizations (38). In the Philippines, the PHIC pays for a so-called “Z Benefit” package for the full treatment course of certain catastrophic illnesses including early breast, colon, and rectum cancers, but not brain cancer. In Indonesia, treatment costs for recurrent glioblastoma are no longer paid for by the BPJSK. This results in dismal follow-up at baseline and at worst, poor long-term survival among patients with malignant intracranial tumors.
The case for subsidizing the full costs of treatment for patients with glioblastoma is justified by its cost-effectiveness (40) and the fact that brain cancer is one of the leading neurological causes of mortality in the Southeast Asian region that are relevant to the neurosurgeon (41). While full subsidies for the Stupp protocol through some form of strategic purchasing appears to be the preeminent solution, the added strategy of using cash transfers for patients with glioblastoma can modify the behavior of the demand-side of neurosurgical care provision. Cash transfers—in which recipients are given some amount of money, often conditional on their adherence to a desired behavior—have been used by social welfare programs to reduce poverty and to incentivize salutary action for a number of public-health interventions (42, 43). Determining the optimal amount of cash transfers can be difficult and controversial but recent evidence from a modelling study suggests a dose-response relationship between the amount of money given and compliance to scheduled surgery (44). The modelling study by Strader et al. noted that until after baseline costs of surgery are paid for by the purchaser—and thus becomes free for the patient—only then can any incremental increase in the amount of cash transfer be expected to improve compliance.
Conditional cash transfers for patients with glioblastomas may be done to decrease the no-show rate in follow-up consultation schedules and improve the all too common problem of loss to follow-up. The direct provision of cash for indigent patients can be made contingent on their adherence to adjuvant treatment following neurosurgical operation for glioblastoma. In turn, the families’ non-medical costs are also subsidized. Furthermore, conditional cash transfers also have positive externalities and can be expected to increase the propensity of the household members to have some degree of trust in the systems of healthcare provision and health financing. In this manner, financial barriers to neurosurgical services are actually lowered and a system is in place to reward beneficial health-seeking behavior that ultimately impacts patient outcomes.