PhilHealth Updates

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FRANCISCO Z. SORIA, JR., MD Philippine Health Insurance Corporation

2013 PCP Annual Convention 7 May 2013

Outline 1. PhilHealth and Universal Health Care (Kalusugang Pangkalahatan) 2. Full case rates policy

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Universal health care or universal coverage

Why universal health care (UHC)? A nation needs a healthy population to prosper and sustain economic and social development.

Health being one of the highest priorities of the people makes it a politically important issue for government to meet people’s expectations.

Promoting and protecting health is a human right and essential to human welfare.

People should have access to universal health care and should not suffer financial hardship paying for it.

World Health Report 2010

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Universal coverage not new but now revitalized

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– WHO's constitution (1948) – Alma-Ata declaration (1978) – World Health Assembly Resolution (2005) – World Health Report on Primary Health Care (2008) – Health Financing Strategy for Asia Pacific Region (2009) Universal Coverage adopted by most countries in their national health plans and/or reform agenda

World Health Report 2010

Towards Kalusugang Pangkalahatan

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Pre-PhilHealth Single public health insurance agency (1995) Health Sector Reform Agenda (1999) FOURmula One (F1) for Health (2005)

The Aquino Health Agenda (2010) Achieving Universal Health Care for all Filipinos – Many of ingredients already in place – PhilHealth – health financing driver – Infrastructure and staffing – Economic growth Still, many Filipinos remain without access to critical health services

Barriers to UHC 1. Exclusion linked to factors outside the health system –

inequalities in income, education and social exclusion associated with e.g. ethnicity, gender and migrant status

2. Weak health systems: Insufficient health workers, medicines and health technologies; ineffective service delivery; poor information systems and weak government leadership

3. Health financing systems that do not function. the other parts of the health system cannot function if the financing system is weak

World Health Report 2010

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Three fundamental health financing problems

1. The need to raise sufficient funds for health – more money for health

2. Heavy reliance on direct out-of-pocket payments to finance health in many countries, discouraging people from seeking care and resulting in financial hardship when they do

3. Inefficiency and inequity in use of resources, reducing the amount of "health for the money“ – more health for the money

World Health Report 2010

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U n i v e r s a l h e a l t h c a r e

WHY NOW?

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a middle income country Highly fragmented health system

Large influential private sector

close to 100M population More unemployed/informal sector

archipelagic nature

Philippines

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P O V E R T Y H E A L T H

Powerful associations have been noted between health and an absolute lack of economic resources

Ill-health can also lead to, exacerbate, and perpetuate poverty

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Large Income-Related Health Outcome Inequalities

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Regional Inequities Are Persistent

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Outline

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Updates on the 23 Case Rates and the

All Case Rates Initiatives

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Source: Langenbrunner

•Case payment/

FFS Partial Case Rates

All Case Rates

Promotes efficiency among HCPs Improve turn-around-time Make the benefits easier to communicate Allow PhilHealth to introduce incentives and NBB Improve transparency and predictability i.e. members know their benefits

All Case Rates Policy

Conceptual Framework

Fee for Service Case Rates

Incentive for efficiency Incentive for quality

Equitable distribution of reimbursement and

better resource management

Critical Step in the Creation and

development of a policy and regulatory

environment for Financial Risk Protection

Co-pay policies and No Balance billing

Outcomes-based Facilities enhancements

Health Expenditure by Source of Funds (2010)

Source: NSCB 24

11%

16%

9%

54%

10% National government

Local government

Social health insurance

Out-of-pocket

Others

Total health expenditure (in billion P)= 379 Health expenditure as % of GDP= 4.2

2010 Premium Payment 29.087 Billion

Benefit payment 30.513 Billion

No of claims 3,479,453 Total benefit payment (in million pesos)

30,513.1

Total benefit payments for drugs and medicines

29% (PHP 8,848,794,079)

For the first time in the history of the NHIP, PhilHealth paid more in benefits than it collected in premium contributions: a difference of 1.5 billion pesos.

Benefit Payment 2010

Medicines comprise about 29% of the total amount paid by PhilHealth amounting to PHP 9B

• Messages • Case Rates and NBB are related but are different

concepts. • Case rates apply to all. NBB only for the

sponsored in government wards. • NBB patients are those that used to not afford to

pay but now will be able to through PhilHealth. (new markets)

• Currently, for non-sponsored member types, there is co-pay. But co-pay is not fixed to the detriment of the “next poor”.

Message to Providers

• stable claims • no fraud/up casing

PROCESS:

Methodology

COSTING •Using 2 sets of codes:

•ICD 10 for medical conditions •RVS for procedures

GROUPING •Conditions and procedures of similar nature and management were grouped together

Method

AVPC of all ICD 10 codes + 20% of the AVPC

Comparison with existing case rates,

PF study, actual rates in database

Medical Case Rates

• Why AVPC? • Source of available data is PHIC dbase • No fair costing studies on PF and hospital charges

Surgical Case Rates

Method

RVU-based rates for professional fees = RVU x 56 x1.5

• Why RVU? • To make PF rate Commensurate to the level expertise of doctors and receive

what they used to get from PHIC

AVPC for facility fee

Implications of case rates to practice (1)

1. Credentialing and privileging to be done at the hospital level

2. Shift in the way physicians and hospitals transact with patients still fee-for-service?

Implications of case rates to practice (2)

3. Need for hospitals/physicians to develop their corresponding service packages for each type of case rated condition/procedure or at least for the most common ones physicians should agree on what drugs,

supplies, diagnostic tests and therapeutic interventions that go with each package and ensure that they are available in the hospital

END