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  • PhilHealth Benefit Packages:

    Understanding the Role of Quality Medicines

    and Quality Pharmaceutical Care

    DR. FRANCISCO Z. SORIA, JR.

    Vice-President

    Quality Assurance Group

  • Outline • Universal health care

    – Definition

    – Aquino Health Agenda

    – National Health Insurance Program

    • PhilHealth benefits

    – Spectrum

    – Drug policy- increasing access, payment mechanism

    – Quality assurance

    – Tsekap

    • Role of pharmacists

  • Universal health care or universal coverage

  • Three strategic thrusts:

    l. Financial risk protection through expansion in NHIP enrollment and benefit delivery

    - the population, especially the poor, will be protected from the financial impact of health care use by improving the benefit delivery ratio of NHIP;

    2. Improved access to quality hospitals and health care facilities

    - upgrading of government-owned health care facilities will be undertaken in order to expand capacity and provide quality services to help attain MDGs, attend to traumatic injuries and other types of emergencies, and manage non-communicable diseases and their complications; and

    3. Attainment of the health-related MDGs

    - public health programs will be focused on reducing maternal and child mortality, morbidity and mortality from TB and malaria, and the prevalence of HIV/AIDS, in addition to being prepared for emerging disease trends, and prevention and control of non-communicable diseases.

    4

    Achieving Universal Health Care through the Aquino Health Agenda

    Source: Department of Health. 2010. Administrative Order No. 2010 - 0036 Subject: The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos

  • 1969- creation of the predecessor organization (Medicare) of

    PhilHealth, which provided health insurance to the

    formal sector (public and private employees)

    1995- PhilHealth was established by law, taking over from

    Medicare and expanding its membership to the indigent

    and the informal sector.

    2014 PhilHealth coverage= 87% of the total population

    benefit payments= P78 billion (2014)

    Implementing the

    National Health Insurance Program

  • Outpatient

    (PCB & MDG)

    Inpatient

    (Case Rates)

    Catastrophic

    (Z benefits)

    Spectrum of PhilHealth Benefits

    Primary Care Benefit

    Maternity Care Package

    Newborn Care Package

    TB-DOTS Package

    Animal Bite Package

    Malaria Package

    Outpatient HIV-AIDS

    Package

    Acute Lymphocytic

    Leukemia

    Early Breast Cancer

    Prostate Cancer

    Kidney Transplantation

    Coronary Artery Bypass

    Graft

    Total Correction of TOF

    Closure of VSD

    Cervical Cancer

    Z Morph

    Peritoneal Dialysis

    Inpatient cases

    Day surgeries

    Chemotherapy

    Radiotherapy

    Hemodialysis

  • Agencies Involved in Medicine Regulation

    Source: NCPAM presentation during Nationwide

    Tsekap Orientation

  • PhilHealth Reimbursement of Medicines

  •  Only drugs included in the essential drugs list (PNF)

    are covered.  For sometime, there was a system of

    identifying a “positive list” of additional drugs after passing health technology assessment; later discontinued.

     Conform with Generic Act requirements (generic terminology, no brand specified)

    Increasing access to medicines

  •  The challenge for PhilHealth is to increase provider efficiency in order to increase financial risk protection.

     This would entail changing the way we pay health care providers.

     Shifting to prospective payment mechanisms such as case payment, capitation and global budget may increase efficiency and promote the use of cheaper quality medicines such as generic medicines.

    Changing the way we do business with providers

  •  Currently, medicines are bundled into the whole benefit package and paid per case (case-based payment or case rates)

     Case-based payment (case rates) encourages efficiency among providers including their use of medicines= low-cost quality drugs over expensive branded ones, use of only the necessary drugs discouraging polypharmacy

     Use of non-PNF drugs and irrational drug use can be detected during post-audit of claims and counted as violation, which may result in suspension of accreditation of health care provider (both professional and institutional)

    Changing the way we do business with providers

  • Section 50 of IRR of R-A. 10606

    The Corporation is mandated to ensure that:

    a.X x x

    b.X x x

    c.Acquisition and use of scarce and expensive medical technologies and

    equipment are consistent with actual needs and standards of medical

    practice and that the performance of medical procedures and the

    administration of drugs are appropriate, necessary and consistent with

    accepted standards of medical practice and ethics and respectful of the

    local culture. Drugs for which payments will be made shall be those

    included in the PNF, unless explicit exception is granted by the

    Corporation;

  • Section 47 of IRR of R-A. 10606 (Guidelines on Claims Payment)

    The Corporation shall penalize health care providers for claims attended by any but not limited to the following circumstances: 1. Overutilization of services 2. Unnecessary diagnostic and therapeutic procedures and

    interventions; 3. Irrational medication and prescriptions; 4. xxx 5. Gross, unjustified deviations from currently accepted standards of

    practice and/or treatment protocols; 6. Xxx 7. Use of fake, adulterated or misbranded pharmaceuticals or

    unregistered drugs; 8. Use of drugs other than those recognized in the latest PNF and

    those for which exemptions were granted by the board;

  • Evolution of PhilHealth’s Primary Care Benefit

    OPB (2000)

    • Sponsored program

    • Gov’t – owned facilities

    • Consultation

    • Diagnostics • Php 300/family/yr

    PCB1 (2012)

    • SP/IP, OG/iG, OWP, DepEd

    • Gov’t – owned facilities

    • Consultation

    • Diagnostics (+2)

    • Medications • Php 500/family/yr

    TSEKAP (2015)

    • SP/IP, Senior Citizens, Kasambhay

    • Gov’t and privately owned facilities

    • Consultation

    • Diagnostics (+5)

    • Medications paid to drug outlets

    • Php 1800/family/yr

  • Criteria Used for Package Contents

    EPIDEMIOLOGICAL FIT

    COST- EFFECTIVENESS

    FEASIBILITY AT THE PRIMARY CARE

    LEVEL

    CAN FUND THE ENTIRE CYCLE OF

    CARE

    ALIGNMENT WITH DOH PROGRAMS AND NHIP MANDATE

  • DRUGS AND MEDICINES

    ASTHMA • Salbutamol

    • Fluticasone

    • Prednisone

    ACUTE GASTROENTERITIS

    • ORS

    • Zinc supplements

    URTI • Paracetamol

    • Amoxicillin

    • Erythromycin

    PNEUMONIA • Paracetamol

    • Amoxicillin

    • Eryhthromycin

    • Co-amoxyclav

    DIABETES

    • Metformin

    • Gliclazide

    • Aspirin

    HYPERTENSION

    • Hydrochlorothiazide

    • Metoprolol

    • Enalapril

    • Amlodipine

    DYSLIPIDEMIA

    • Simvastatin

    UTI • Ofloxacin

    • Cotrimoxazole

    • Co-amoxyclav (pregnant)

    DEWORMING

    • Mebendazole

    ISCHEMIC HEART DISEASE

    • Aspirin

    • Atenolol

    • Isosorbide Mononitrate

    NEW

    PCB2 PCB2 PCB2

    NEW NEW

  • COST OF TSEKAP PACKAGE

    P800 MAXIMUM

    for Services & Diagnostics

    P1,000 MAXIMUM for

    Medicines

    P 1,800 cost per family

    Capitation Paid to Tsekap Providers

    Paid to accredited drugstores, per meds prescribed by Tsekap Providers

  • DRUG PRICE REFERENCE INDEX

    • Ceiling price for government bidding and procurement set by DOH for all DOH facilities based on prevailing tender prices of essential medicines

    • Used lowest winning bids

    • Identified median procurement price (unit cost) for each molecule and strength. If less than 3 suppliers, DPR is set at lowest procured price.

    *Conducted by Department of Health – National Center for Pharmaceutical Access and Management

  • Medicine Generic Name

    Dosage/Strength Form Price Cap for

    PhilHealth Reimbursement

    1 Amlodipine 5 mg Tablet 1.55

    10 mg Tablet 1.82

    2 Amoxicillin

    100mg/mL 10 ml Drops 40 100mg/mL 15 ml Drops 41

    125mg/5mL 60 ml Suspension 19.46 250mg/5mL 60 ml Suspension 29.90

    250 mg Capsule 1.33 500 mg Capsule 1.66

    3 Aspirin 80mg Tablet 1.69

    4 Atenolol 100mg Tablet 11.69 50mg Tablet 2.64

    5

    Co-Amoxiclav (Amoxicillin +

    Potassium Clavulanate)