PIDS, World Bank push smarter use of PhilHealth data

Philippine health authorities are exploring how to maximize PhilHealth claims data to accelerate universal health care (UHC), with more than 15 million claims processed in 2024 alone.

“Claims data tell a much bigger story than just the cost of care,” said Dr. Valerie Gilbert Ulep, program director of the Philippine Institute for Development Studies–Health Economics and Finance Program (PIDS-HEFP).

“They show us not just who gets sick, but how the country’s health care system responds, and whether that response is fair and effective,” he added.

At a recent workshop co-organized by PIDS-HEFP and the World Bank Group, with support from the Australian Government’s Advance UHC initiative, policymakers and data experts examined how insurance claims data could inform evidence-based health reforms.

Held at Marco Polo Ortigas Manila, the event titled “Data-Driven Decision-Making for UHC: Leveraging Health Insurance Claims Data” highlighted how PhilHealth’s trove of claims records could enhance efficiency, equity, and accountability in health service delivery.

The workshop also offered insights into how claims data can strengthen health system analysis and inform strategic decisions.

Organizers aimed to help participants “see beyond spreadsheets” by connecting statistics to patient experiences and measurable policy outcomes.

World Bank lead economist Dr. Ajay Tandon said analyzing claims data can help identify where hospitals are efficient or overburdened, and whether patients receive appropriate care on time.

Preliminary analysis showed that one in three inpatient claims were for ambulatory-care-sensitive conditions, or illnesses that could have been prevented with effective primary care.

PIDS analysts noted that this trend likely indicates both supply- and demand-side challenges in accessing primary healthcare.

They added that patterns in data on procedures such as cesarean deliveries, readmissions, and tobacco-related illnesses can guide decisions on where to allocate health resources more effectively.

The workshop builds on PIDS-HEFP’s broader efforts to implement Diagnosis-Related Groupings (DRGs), a provider payment mechanism mandated under Republic Act No. 11223, or the UHC Law.

Under the DRG system, hospitals are reimbursed based on quality and efficiency of care rather than volume of services.

The same data analytics featured in the training are essential for setting DRG rates and monitoring their implementation and outcomes.

Over the past year, PIDS-HEFP has engaged with PhilHealth, the Department of Health, and medical societies to prepare hospitals for pilot testing of the DRG model.

The new push to analyze PhilHealth claims data is part of this continuum, transforming administrative records into insights for long-term health policy.

The workshop is the latest in a series of capacity-building activities led by PIDS-HEFP, including the nationwide DRG awareness campaign, technical briefings for hospital administrators, and forums with health professionals.

Each initiative supports a shared goal: a transparent, data-informed health financing system that delivers “Dapat, Sapat, Tapat” care for every Filipino.