1st quarterly seminar and meeting the national health ...and non-formal sector premium paid through...

GREGORIO C. RULLODA

OIC-Senior Vice President

& Chief Finance Executive

Fund Management Sector

The National Health

Insurance Fund

and

PhilHealth Enhance Benefits : “Building a High-Trust

Society Thru Strong

PFM Leading to Shared

Growth”

1st Quarterly

Seminar and

Meeting

Philippine Association for Government Budget Administration (PAGBA)

2017 1st Quarterly Seminar & Meeting, April 5-8, 2017

Crown legacy Hotel, Baguio City

Presentation Outline

The Philippine Health Agenda

PhilHealth Updates




P H I L I P P I N E H E A L T H A G E N D A 2 0 1 6 - 2 0 2 2




GOALS

The Health System We Aspire For

Filipinos, especially the Filipinos attain the

best possible

health outcomes

with no disparity

Filipinos feel respected,

poor are protected from high cost of health care

valued, and empowered in all of their interaction with

the health system

RESPONSIVENESS

BETTER HEALTH

OUTCOMES

FINANCIAL

PROTECTION




• UNIVERSAL HEALTH COVERAGE

• STRENGTHEN IMPLEMENTATION OF

RPRH LAW

Investing in People • WAR AGAINST

DRUGS

• ADDITIONAL FUNDS FROM PAGCOR

Protection Against Instability




PHILIPPINE HEALTH AGENDA FRAMEWORK

UNIVERSAL HEALTH

INSURANCE

A C H I E V E

3 Guarantees

SERVICE DELIVERY

NETWORK

ALL LIFE STAGES & BURDEN OF DISEASES

Goals: Attain Health-Related SDG Targets

Financial Risk Protection, Better Health Outcomes, Responsiveness

Values: Equity, Efficiency, Quality, Transparency




ALL LIFE STAGES & TRIPLE BURDEN OF

DISEASE Services for Both the Well & the Sick

GUARANTEE #1




All Life Stages & Triple Burden of Disease

Pregnant Newborn Infant Child Adolescent Adults Elderly

First 1000 days | Reproductive and sexual health | maternal, newborn, and child

health | exclusive breastfeeding | food & micronutrient supplementation |

Immunization| Adolescent health | Health screening, promotion & information

• Cancer, Diabetes, Heart

Disease and their Risk

Factors – obesity,

smoking, diet,

sedentary lifestyle • Malnutrition

• •

•

•

•

Injuries Substance abuse

Mental Illness

Pandemics, Travel Medicine

Health consequences of

climate change / disaster

• •

•

HIV/AIDS, TB, Malaria Diseases for Elimination

Dengue, Lepto, Ebola,

Zika

DISEASES OF RAPID URBANIZATION & INDUSTRIALIZATION*

NON-

COMMUNICABLE,

INCLUDING

MALNUTRITION

COMMUNICABLE




SERVICE DELIVERY NETWORK Functional Network of Health Facilities

GUARANTEE #2




Services are delivered by networks that are

TO THE PEOPLE

ENHANCED BY

TELEMEDICINE

AVAILABLE 24/7 & EVEN

DURING DISASTERS

LOCATED CLOSE

(Mobile Clinic or Subsidize

Transportation Cost)

COMPLIANT WITH CLINICAL

PRACTICE GUIDELINES

PRACTICING GATEKEEPING

FULLY FUNCTIONAL (Complete

Equipment, Medicines, Health

Professional)




UNIVERSAL HEALTH INSURANCE Financial Freedom when Accessing Services

GUARANTEE #3




Services are financed predominantly by PhilHealth

accommodation

accommodation

range of services with high support value

• Formal sector premium paid through payroll

tax subsidy

PHILHEALTH AS

THE GATEWAY TO

FREE OR

AFFORDABLE CARE

• All Filipinos as members

and non-formal sector premium paid through

PHILHEALTH AS

THE MAIN

REVENUE SOURCE

FOR ALL

HEALTHCARE

FACILITIES

• Expand benefits to cover comprehensive

• Contracting networks of providers within Service

Delivery Networks

SIMPLIFY

PHILHEALTH

RULES

• No balance billing for the poor in basic

• Fixed co-payment for non-basic




STRATEGIES

A

Advance health promotion, primary care and quality

C

Cover all Filipinos against financial health risk

H

Harness the power of strategic Human Resource for Health

I

Invest in eHealth and data for decision-making

E

Enforce standards, accountability and transparency

V

Value clients and patients

E

Elicit multi-stakeholder support for health




LGU

• Conduct annual health visits for all poor families

and special populations (NHTS, IP, PWD,

Senior Citizen)

• Collaborate with others to form networks

• Expand primary care benefit to all members

• Limit contracting of

PCB providers with

functional networks

(not stand-alone)

• Facilitate the process

of network forming

• Upgrade 3 DOH

hospitals into “mega-

hospitals”

A

Advance health promotion, primary care and quality




LGU

• Undertake costing and

revise case rates

Increase

premium rates and

collection efficiency

Design additional benefits for outpatient diagnostics, drugs, blood & blood products

• Support revenue

generation measures

Align all health financial • •

assistance programs

support Universal

Health Coverage

(PAGCOR, PCSO)

to

•

C

Cover all Filipinos against financial health risk

• Implement Health Trust Funds

• Provide income

retention to health

providers while

retaining budgetary

support




• Streamline

compensation scheme

for health workers

• Form Legislative-

Executive Health

Human Resource

Task Force

2016 – 2017

H

Harness the Power of Strategic HRH

LGU

• Provide the

Magna Carta

HCW benefit




LGU

Implement EMR in all health facilities

Improve local civil

registration and vital

statistics data

Submit data

electronically

• Revise accreditation/

contracting rules to reflect

regular electronic

submission requirement

Open up data set for

researchers

Provide incentives

• • Revise licensing

requirements to reflect

regular electronic data

submission requirement

Open up data set for

researchers

•

•

• •

•

I

Invest in eHealth and data for decision-making




LGU

Ensure transparent

procurement

process in all health

facilities

Regularly submit data

to DOH

• Publish annually

accountability

report card

• • Collect and publish

relevant information

Publish annually

accountability

report card

•

•

E

Enforce accountability and transparency




LGU

Set up complaints & redress mechanisms

• Streamline

procedures for availing services

• • Coordinate with PhilHealth in

defining the

healthcare

entitlements of

every Filipino

and publish this

Set up call center •

V

Value clients and patients, especially the poor and vulnerable




LGU

Implement healthy

communities/

cities

interventions

• Expand contracting

mechanisms to

include the private (Z

benefits, PCB)

• • Develop policy

agenda

with NGAs, CSOs and

private sector on

mainstreaming Health

in All Policies

Institutionalize health

impact assessment for

large scale projects

•

E

Elicit multi-sector multi-stakeholder support for health




Vision




Bawat Pilipino MIYEMBRO




Attainment of

Universal

Coverage

Special Provisions in the 2017 GAA




ATTAINMENT OF UNIVERSAL COVERAGE

To attain a universal health coverage, the amount of Three Billion Pesos (P3,000,000,000) is appropriated herein and shall cover all Filipino citizens that are not covered under the above special provisions no. 1 and 2 and are not formally employed with the government or private sector, either with regular appointment or casual appointment.

Thru Point of Service




Accreditation Institutional Health Care Providers (IHCP)

Particulars Government Private Total

Accredited Hospitals and Infirmaries

746 1,111 1,857

Particulars Primary Care Benefit Package

Maternity Care

Package

DOTS Package

Number of Accredited Outpatient Clinics

2,474 2,777 1,804

No. of cities & municipalities with Accredited OP Clinics*

1,529

1,389

1,314

% to total cities & municipalities

94%

85%

80%

A city or municipality may have more than one outpatient clinic accredited by PhilHealth to provide NHIP benefits and services.

Note : Includes all accredited hospitals and infirmaries

There are 1,634 LGUs nationwide.

Accredited

Health Care

Professionals:

31,814

Accredited Collecting Agents (ACAs) No. of

ACAs

No. of

Branches

Local Collections:

Universal Banks 13 3,205

Commercial Banks 6 360

Thrift Banks 9 560

Rural Banks 9 194

Private Non-banks 3 4,108

Gov't Non-banks

• PhilPost 1 1,393

• Local Government Units 206 181

Sub-total 247 10,001

Overseas Collections:

Universal Banks 2 5

Commercial Banks 2 37

Private Non-banks 2 481

Sub-total 6 523

Grand Total 231 10,524

CONTRIBUTIONS

MEMBERSHIP CONTRIBUTION AMOUNT

FORMAL

ECONOMY

Sharing of Employer &

Employee (50%-50%) through

payroll deduction: 2.5% of

basic salary

up to P8,000: P200 (P100

ee/er per mo.)

P35,000 up: P875)

(P437.50 ee/er per mo.)

INFORMAL

ECONOMY

100% Contribution by the

Member

P2,400/annum

MIGRANT

WORKERS

100% Contribution by the

Member

P2,400/annum

INDIGENTS 100% subsidy by the National

Government

P2,400/annum

SENIOR CITIZENS 100% subsidy by the National

Government

P2,400/annum

SPONSORED 100% Subsidy by the Sponsor

or Partial Subsidy

P2,400/annum

LIFETIME

None Paid at least 120 months

and reached the age of

60

PhilHealth Circular No. 2016-008

Statement of Premium Account (SPA) in all

Employer Remittances

• No SPA No Payment

• SPA number as the main reference by ACAs

• Effectivity: July 2016 premium payments for applicable month of June 2016 onwards

Publication: Philippine Daily Inquirer/June 4, 2016




Range of PhilHealth Benefits:

1. Inpatient Benefits

2. Outpatient Benefits

3. Primary Care Benefits (PCB)

4. Catastrophic or Z Benefits

5. MDG and Other Special Benefits

New and Enhanced PhilHealth Benefits




Range of PhilHealth Benefits:

4. Inpatient Benefits

5. Catastrophic Benefits

3. Other Benefit Packages

2. Outpatient Benefits/Coverage

1. Primary Care Benefits (PCB)

Bawat MIYEMBRO, Protektado

Inpatient Benefits Benefits for sickness or ailments that need confinement of not less than 24

hours

What are covered • Both medical and Surgical (or procedural) cases

• Accredited Health Care Providers (Hospitals, Primary Care Facilities -infirmaries and dispensaries)

Who provides

• Facility fee: Room and Board, drugs/meds, labs/diagnostics etc.

• Professional Fee

What services

• Case based payment-fixed rate across all member categories

Payment Mechanism




Inpatient Benefits - Medical Case (partial list only)

Medical Conditions

1 Dengue Fever P10,000.00

2 Dengue, Severe P16,000.00

3 Pneumonia Moderate Risk P15,000.00

4 Pneumonia High Risk P32,000.00

5 Hypertensive Emergency / Urgency P 9,000.00

6 Stroke - Infarction P28,000.00

7 Stroke - Hemorrhagic P38,000.00

8 Acute Gastroenteritis P 6,000.00

9 Asthma in Acute Exacerbation P 9,000.00

10 Typhoid Fever P10,000.00

Outpatient Benefits Day surgeries and treatment procedures done in accredited hospitals

and free-standing clinics that don’t require confinement

What are covered • Procedures/surgeries with less than 24 hrs

confinement or outpatient basis

• Accredited Health Care Providers (Hospitals, Ambulatory

Surgical Clinics, Primary Care Facilities, Dialysis Clinics,

Maternity Clinics/Lying –in clinics, Animal Bite Treatment

Centers, TB DOTS clinics}

Who provides

• Facility fee: Room and Board, drugs/meds, labs/diagnostics etc

• Professional Fee

What services

• Case based payment-fixed rate across all member categories

Payment Mechanism




Outpatient Benefits (partial list only)

1 Cataract Package P 16,000.00

2 Radiation Treatment Delivery or Radiotherapy

P 3,000.00

3 Outpatient Blood Transfusion P 3,640.00




Catastrophic Benefits (Z Benefits) (Life threatening & costly)

1. Acute Lymphocytic / Lymphoblastic

Leukemia

(standard risk)

P 210,000

2. Breast Cancer (stage 0 to IIIA) P 100,000

3. Prostate Cancer (low to intermediate risk) P 100,000

4. End-state renal disease eligible for

requiring kidney transplantation (low risk) P 600,000

5. Coronary Artery Bypass Graft Surgery

(standard risk) P 550,000

6. Surgery for Tetralogy of Fallot in Children

(Blue Baby Syndrome) P 320,000




Catastrophic Benefits (Z Benefits)

7. Surgery for Ventricular Septal Defect in

Children P 250,000

8. Cervical Cancer:

- Chemoradiation with Cobalt and

Brachytherapy (low dose) or Primary surgery

for Stage IA1, IA2 – IIA1

- Chemoradiation with Linear Accelerator and

Brachytherapy (high dose)

P 120,000

P 175,000

9. Z MORPH (Mobility, Orthosis, Rehabilitation,

Prosthesis Help)

- first right and/or left below the knee

- both limbs

P 15,000

P 30,000

10. Selected Orthopedic Implants (see next

slide)

11. End-Stage Renal Disease Requiring

Peritoneal Dialysis P 270,000




12. COLON Cancer

Stage I to II (low risk) P 150,000

Stage II (high risk) to III P 300,000

13. RECTUM Cancer

Stage I (clinical and pathologic) P 150,000

Stage II to III (using linear accelerator) P 400,000

Stage II to III (using cobalt) P 320,000

Catastrophic Benefits (Z Benefits)




Selected Orthopedic Implants

IMPLANTS Rates per side

(left or right)

Total Hip Prosthesis , cemented* P 105,000.00

Total Hip Prosthesis , cementless** P 175,000.00

Partial Hip Prosthesis, bipolar P 85,000.00

Multiple screw fixation (MSF)* ** P 65,000.00

Compression Hip Screw Set (CHS) P 80,000.00

Proximal Femoral Locked Plate (PFLP) P 80,000.00

Intramedullary Nail with Interlocking

Screws P 55,000.00

Locked Compression Plate (LCP) -

Broad/Metaphyseal/ Distal Femoral LC P 55,000.00




Other Benefits

Moderate Leptospirosis

Package

Php11,000

Ebola (confirmed) P110,000 For confinements of 7 days

or less (+P16,000/day beyond 7 days

MERS-CoV

(as confirmed by RITM)

up to P50,000

(non-health workers)

up to P100,000

(health workers)




e-PhilHealth Services




“PhilHealth AllCase Rates (ACR) Search” Mobile

Application




1. Enter the ICD 10 Code/RVS

Code/Description then press

“Search”

2. No. of record/s

will display

then select “Ok”

3. Search results will

display. Select the final

diagnosis you are

looking for.

HOW TO USE?




4. Case rate details will display.

There is an option to choose the

type of HCI.




88 or 66% (Excellent)

1 or 1% (Outstanding)

44 or 33% (Good)

133 Frontline Units

Surveyed (47%)

ARTA-Report Card Survey




PhilHealth ISO Certified




Comparative Financial Position (in billions)

As of December 31, 2016

FS - Unqualified

Opinion

www.facebook.com/PhilHealth

www.twitter.com/@teamphilhealth

e-mail [email protected]

www.philhealth.gov.ph

CONTACT US!




http://www.philhealth.gov.ph/

1st quarterly seminar and meeting the national health ...and non-formal sector premium paid through...

Documents