PhilHealth Benefit Packages: Understanding the Role of...

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)

125 mg + 31 mg/5ml 60 ml Suspension 130.00 1 g Tablet 25.87

200 mg + 28.5 mg/5 ml 70 ml Suspension 201.50 250 mg + 62.5 mg/5ml 60 ml Suspension 201.50 400 mg + 57 mg/5 ml 70 ml Suspension 227.50

625 mg Tablet 14.16

6 Cotrimoxazole

(Sulfamethoxazole+ Trimethoprim)

200mg+40mg/5ml 60 ml Suspension 20.67 400 mg + 80mg Tablet 0.96

400mg+80mg/5ml 60 ml Suspension 21.39 800 mg + 160mg Tablet 1.56




7 Enalapril 10mg Tablet 5.45

20mg Tablet 8.45 5mg Tablet 6.03

8 Erythromycin 200 mg/5ml 60 ml Suspension 70.79

500 mg Tablet 5.33

9 Fluticasone +

Salmeterol 125 mcg + 25 mcg x 120

doses Metered Dose Inhaler 163.80

10 Gliclazide 30 mg MR Tablet 6.10 80 mg Tablet 4.62

11 Hydrochlorothiazide 25mg Tablet 1.03

12 Isosorbide-5-Mononitrate

20 mg Tablet 5.20 60 mg MR Tablet 11.70

13 Mebendazole 500 mg Tablet 4.68

100mg/5ml 30mL Suspension 23.66

14 Metformin

Hydrochloride 500 mg Tablet 1.00

15 Metoprolol (as Tartrate)

100 mg Tablet 2.57 50 mg Tablet 1.42




16 Ofloxacin 200 mg Tablet 5.72 400 mg Tablet 5.71

17 Oral Rehydration Salts

(ORS 75-replacement) 75 Replacement 2.17 g

Sachet 3.67


Sachet 6.08


250 ml bottle 58.50

18 Paracetamol

100mg/ml 15 ml drops 18.01 125 mg/5ml 60 ml bottle 20.28 250 mg/5ml 60 ml syrup 21.29

125 mg Suppository 13.73 250 mg Suppository 14.27 500 mg Tablet 0.30

19 Prednisone 5 mg Tablet 0.73

10 mg Tablet 4.94 20 mg Tablet 6.24


Dosage/Strength Form Price Cap for PhilHealth

Reimbursement

20

Salbutamol (as Sulfate) +

Ipratropium Bromide 500 mcg+2.5 mg/2ml Nebule 14.79

Salbutamol

100 mcg/dose x 200 doses Metered Dose Inhaler 90.87 1mg/ml 2.5ml Nebule 4.06

2 mg tablet 0.48 2 mg/ml 2.5ml Nebule 3.51

2 mg/5ml 60 ml syrup 22.10

21 Simvastatin 10 mg tablet 4.16 20 mg tablet 1.89 40 mg tablet 7.84

22 Zinc 27.5mg/ml 15 ml oral drops 49.40 55mg/5ml 60 ml syrup 50.05

Monitoring Framework

• Anchored in the Health Care Provider Performance Assessment System of the Corporation to evaluate the following parameters:

– Quality of care

– Access to Tsekap services

– Patient satisfaction

– Financial risk protection to members

– Fraud detection

43 Priority Provinces Region Province

# of NHTS members (Feb 2015)

Total # of Mun/Cities

# of Mun/Cities w/ PCB1 provider

# of PCB1 providers

1 Ilocos Norte 74319 23 23 24

567054 Ilocos Sur 87313 34 33 34

Pangasinan 405422 48 48 62

2 Cagayan 181401 30 28 31

480193 Isabela 212001 40 38 44

Nueva Vizcaya 59114 14 14 17

Quirino 27677 7 7 10

3 Aurora 26787 8 4 4

236258 Pampanga 149165 29 21 39

Zambales 60306 14 12 16

4a Cavite 143651 20 18 27

554447 Laguna 126553 28 28 43

Quezon 236103 41 39 48

Rizal 48140 14 13 25

43 Priority Sites Region Province

# of NHTS members (Feb

2015)


# of Mun/Cities w/ PCB provider

# of PCB1 providers

5 Camarines Sur 220681 37 35 46

438849 Catanduanes 57423 11 11 18

Masbate 160745 21 19 19

6 Antique 114301 18 18 26

450902 Iloilo 296374 47 46 66

Negros Occidental

40227 33 32 43

7 Bohol 231900 46 45 51

711600 Cebu 479700 53 52 74

8 Eastern Samar 110883 23 22 32

724307 Leyte 381976 44 42 62

Northern Samar 152711 24 23 23

Southern Leyte 78737 18 16 16

43 Priority Sites Region Province

# of NHTS members (Feb 2015)


# of Mun/Cities w/ PCB provider

# of PCB1 providers

9 Zamboanga del Norte 375199 27 26 30

897433 Zamboanga del Sur 320023 48 48 48

Zamboanga Sibugay 202211 16 16 16

10 Camiguin 14313 5 5 6

11 Davao del Sur 195912 16 12 28

12 Cotabato City 23920 1 1 1

138539 Saranggani 114619 8 7 7

CAR Abra 43169 27 18 23

88413 Apayao 23383 8 8 8

Benguet 21861 14 14 30

CARAGA Agusan del Sur 142573 15 14 16

407276 Dinagat Island 30856 7 7 7

Surigao del Norte 100581 29 29 29

Surigao del Sur 133266 19 18 20

43 Priority Sites

Region Province # of NHTS members (Feb 2015)


# of Mun/Cities

w/ PCB provider

# of PCB1 providers

ARMM Lanao del Sur 189765 40 40 41

920221 Maguindanao 475066 36 31 31

Sulu 255390 20 13 14

TOTAL 43 6825717 1061 1009 1255

DOH • Certify facilities as eligible to be Tsekap providers based

on the standards

– Referral facilities for Level 2 laboratory services, Chest x-ray and ECG

– part of the Service Delivery Network (AO 2014 – 0046)

• Certification of IT requirements:

– iClinicsys operational

– Certification of other qualified EMR providers

• NCPAM to supply all Tsekap drugs for areas with no partner Drug outlets

ENGAGING PHARMACISTS

RESPONSIBLE DISPENSING

PATIENT COUNSELLING

MEMBER OF THE HEALTH

TEAM ADVOCACY

P R I M A R Y H E A L T H C A R E M O V E M E N T



QUALITY CONTROL

• Safeguarding procurement, storage and distribution of drugs

• Dispensing medications according to doctor’s prescription

• Ensuring proper documentation of all transactions for monitoring activities

PATIENT COUNSELLING

MEMBER EMPOWERMENT

• Helping members understand the disease being treated

• Providing guidance on proper intake of medications including dosage and possible side-effects

PATIENT COUNSELLING

MEMBER EMPOWERMENT

• Connecting the medicine prescribed with necessary lifestyle changes to ensure drug effect

• Develop advisories in response to common diseases in the community

MEMBER OF THE HEALTH

TEAM

TEAM APPROACH IN CARE

• Communicating and cooperating effectively with other members of the health care team

• Ensuring that the member is in the center of the therapeutic plans

ADVOCACY

PRIMARY HEALTH CARE

• Cornerstone of Universal Health Care and PNoy’s Kalusugang Pangkalahatan

• UHC cannot be achieved without responsive primary care

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