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 29108

385474

627709

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 0.291.55

6.57.17

20.2

25.50

28.3929.39

12.15

0

5

10

15

20

25

30

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

In m

illio

ns o

f p

eso

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