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  • PhilHealth TB DOTS Out-patient Benefit Package

    WHO Consultation

    Eliminating the Catastrophic Economic Burden of TB: Universal Health Coverage and Social Protection Opportunities

    April 29, 2013

    Sao Paulo, Brazil

    Dr. Mary Antonette Yason Remonte

    MDG Benefit Products Team Head

    Philippine Health Insurance Corporation

  • Outline

    • Overview of Health System And Health Care Financing

    • Current Efforts

    • Challenges

    • Future Directions

  • Health Care In the Philippines

    • Large informal sector

    • Highly decentralized

    • Free market

    – Large private sector

    – Cost of services unregulated

    • Out of Pocket expense remains high

  • 11%

    15%

    9% 53%

    10%

    2%

    National Government

    Local Government

    Social Insurance

    Out of Pocket

    Private Sector

    Foreign Funding

    Health Care Expenditure 2010

    Source:NCSB

  • Health Care Financing Flow

  • Current Status of TB in the Philippines

    • 15th high burden countries in the world (Global TB Report 2012)

    • Prevalence 4.7/1000 (NTPS 2007)

    • MDRTB 3.9/1000 (NTPS 2007)

    • 8th leading cause of morbidity (FHSIS 2009)

    • 25% with TB did not consult any provider (FHS 2011)

  • Treatment Success Rate 2011

    Source: NTP

  • 2010-2016 Philippine Plan of Action to Control Tubeculosis

    • Localized implementation of TB Control

    • Monitor health system performance

    • Engaged both public and private providers

    • Promote positive behavior of commmunities

    • Address MDR TB, TB-HIV, and vulnerable populations

    • Regulate and make available diagnostic tests and drugs

    • Certify and accredit TB care providers

    • Secure adequate funding and improve allocation and efficiency of fund utilization

  • Universal Health Care

    Financial

    Risk

    Protection

    Improving

    Access to

    Quality

    Health

    Facilities

    Attainment of

    MDGmax

    Better health

    outcomes

    Responsive health

    system

    Equitable &

    sustainable health

    financing

    Health

    Financing

    Service

    Delivery

    Policy,

    Standards and

    Regulation

    Health

    Human

    Resource

    Health

    Information

    Governance

    for Health

  • Universal Health Care • Financial Risk Protection

    – Enrollment of the poor to SHI by the National Government (5 million thru NHTS-PR)

    – Coverage of catastrophic cases (Z benefits)

    – No balance billing policy for the poor

    • Access to quality health services

    – Health facilities enhancement

    • 1,178 RHUs upgraded

    • Attainment of health related MDG goals

    – Focus on MCP, NCP, TB DOTS

  • PhilHealth Financing TB

    Preventive: BCG

    vaccine for Newborns

    TB Screening

    and Diagnosis

    TB DOTS Treatment

    Screening and

    Diagnosis for DRTB

    Treatment for DR TB

    In-patient Admission

    PCB 1 Package

    (Capitation)

    TB DOTS Out-patient

    Package (new Cases)

    (Case Rate)

    In-Patient Benefit (Fee for Service )

    Newborn Care

    Package (Case Rate)

    Vaccine thru EPI

    Supplies thru NTP

    Meds and supplies thru NTP

    Supplies/ capital outlay

    thru NTP

    Meds and Supplies thru NTP

    DOH owned

    hospitals

    PhilHealth

    DOH

  • • Qualified dependents of members

    • No limit as to number of births

    Who can avail

    • Non-hospital facilities

    • Maternity and Lying-in Clinics

    • Hospitals Who provides

    • Newborn care

    • Screening tests – newborn screening and hearing

    • Vaccination – hepatitis B and BCG • EINC protocol

    What services

    • P 1,750

    • No balance billing

    Important Features

    Newborn Care Package

  • • Sponsored Program – NHTS and LGU Sponsored

    • Organized Group

    • Overseas Workers Program

    Who can avail

    • Rural Health Centers

    • Health Centers

    • Out Patient Department of Government Hospitals

    Who provides

    •Primary Preventive Services-

    •Diagnostic Examinations – including sputum examination •Medicines for Common diseases

    What services

    •Assignment and enlistment of PhilHealth member to Primary Care Provider

    • Individual Health Profile – including symptoms suggestive of TB •Electronic reporting with additional incentives

    Important Features

    Primary Care Benefit 1 Package

  • • Members and qualified dependents Who can avail

    • TB DOTS Centers (RHUs, private clinics, OPDs of hospitals) Who provides

    • Service fee

    • Drugs and medicines

    • Follow – up sputum smear What services

    • P 4,000 Important Features

    TB DOTS Package

  • • Members and qualified dependents Who can avail

    • hospitals Who provides

    • Room and board

    • Professional fees

    • Medicines and supplies

    • Laboratory and other diagnostics

    What services

    • For admissions only

    • Case rate and fee for service

    Important Features

    In –Patient Benefits

  • Challenges

    • 53% of towns and cities have accredited TB DOTS facilities

    • Low utilization

    • Incomplete claims – defaulters?

  • Number of PhilHealth Engaged TB DOTS Providers

    8 29 108

    385 474

    627 709

    813

    1090

    1201

    0

    200

    400

    600

    800

    1000

    1200

    1400

    2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

    PCB Providers 2138

    Source: PhilHealth AD

  • 0 0.29 1.55

    6.5 7.17

    20.2

    25.50

    28.39 29.39

    12.15

    0

    5

    10

    15

    20

    25

    30

    2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

    In m

    ill io

    n s o

    f p

    e s o

    s

    Year

    TB DOTS Package Reimbursement

    Note: partial data for 2012

    Source; PhilHealth TFI

  • Source: PhilHealth TFI

  • Future Directions • Simplified accreditation approach

    • PhilHealth Engagement thru Accreditation & Contracting of Health Services

    – Automatic Accreditation, decentralization

    • Increased coverage of the poor – Sin Tax Law  premium for next quintile

    • Increase coverage for the TB conditions – Category II to be included in TB DOTS Package

    – MDRTB  for study

    • Improved quality of care – payment upon completion of treatment

    – Quality standards for out-patient facilities  on the works

  • Health Care Financing Flow

  • Health Care Financing Flow