Issues, Challenges, and Ways Forward for PhilHealth’s Health Information System under a Diagnosis-Related Grouping-Global Budget (DRG-GB) Regime

In this study, the readiness of PhilHealth’s health information system (HIS) to support the transition to Diagnosis-Related Groups with Global Budgets (DRG-GB) as envisioned in the Universal Health Care Act of 2019 was assessed. Using a framework that examines data generation, fiduciary management, and performance analysis, systemic weaknesses across all three domains were identified. The claims system produces incomplete coded data, with ungroupable claims and inadequate feedback mechanisms undermining case-mix measurement; fiduciary oversight is affected by fragmented and manual fraud detection, non-integrated clinical and financial records, and limited technical capacity; and performance monitoring is hindered by siloed systems, the absence of standardized indicators, and weak hospital benchmarking. These challenges could potentially limit PhilHealth's ability to generate reliable DRG tariffs, enforce accountability, and monitor provider behavior with this new payment system. Strengthening coding standards, integrating clinical and financial data, modernizing digital infrastructure, and institutionalizing real-time performance monitoring are critical to ensuring effective DRG-GB implementation and achieving UHC goals. Comments to this paper are welcome within 60 days from the date of posting. Email publications@pids.gov.ph.