PHILHEALTH UPDATESPHILHEALTH UPDATES22ndnd Semi-Annual Hospital Managers Meeting Semi-Annual Hospital Managers Meeting

OUTLINE OF PRESENTATION

I.PhilHealth Directions in Relation to KP Including Status of PhilHealth Membership, Collection and EngagementII.Implementing Rules and Regulations of RA 10606III.New PhilHealth ProgramsIV.Benefits Payment and AvailmentV.Open Forum

Atty. Jerry F. IbayRegional Vice PresidentPhilHealth-CAR

Synergy for Universal Health Care

KP Vision

Financial Risk Protection

Access to Improved Health Facilities

Attainment of Health-related MDG

Bawat Pilipino Miyembro

Bawat Miyembro Protektado

Kalusugan Natin Segurado

Outcomes and Strategies of UHC

Outcome 2: Financial Risk Protection

Strategy 1: Expand PhilHealth CoverageAction Status TARGETS

2014 2015 2016

1. Enroll NHTS poor & near-poor families

5.2 M 14.7 M* 14.7 M 14.7 M

2. Increase hospitals with point of care enrollment

LGU

DOH

100

72

200

72

300

72

3. Enroll the remaining informal sector

80%3.1M not

enrolled but can pay premium

85 88 90

* Depends on NHTS list of DSWD

84%

76%86%

Number and Percentage Distribution of Members and Dependents as of September 2013, CAR

2011 2012 2013LICENSED ENGAGED LICENSED ENGAGED LICENSED ENGAGED

ABRA 10 9 9 9 10 9APAYAO 7 7 7 7 7 7BAGUIO CITY 8 6 8 6 8 6BENGUET 9 9 9 9 9 9IFUGAO 8 8 8 8 8 8KALINGA 9 8 7 7 8 8MT. PROVINCE 7 7 7 7 7 7TOTAL 58 54 55 53 57 54

Summary of Licensed vs Accredited/Engaged Hospitals per province per year:

Hospitals With Out-Patient Benefit Package Services

OPB Services Province/City Hospital

TBDOTS BenguetBaguio City

Benguet Gen. Hospital (BeGH) Baguio Gen. Hospital & Medical Center (BGHMC) St. Louis Hospital of the Sacred Heart (SLUHSH) Notre Dame de Chartres Hospital

Hemodialysis BenguetBaguio City

BeGH BGHMC SLUHSH Notre Dame de Chartres Hospital Pines City Doctors’ Hospital

Animal Bite AbraKalinga

Mt. Province

Abra Provincial Hospital Kalinga Provincial Hospital Western Kalinga District Hospital Bontoc General Hospital Luis Hora Memorial Regional Hospital

Hospitals With Out-Patient Benefit Package Services

OPB Services Province/City Hospital

PCB Abra

Apayao

Baguio City

Abra Provincial Hospital

Bucay MunicipalHospital Dolores Medicare and Community Hospital La Paz District Hospital Villaviciosa Medicare and Community Hospital

Amma Jadsac District Hospital Flora District Hospital Sta. Marcela Med. and Community Hospital Far North Luzon Gen. Hosp. & Trng. Center

Baguio Gen. Hospital and Medical Center

Hospitals With Out-Patient Benefit Package Services

Province/City Hospital

PCB Kalinga

Mt. Province

Kalinga Provincial Hospital Juan M. Duyan District Hospital Kalinga District Hospital Pinukpuk District Hospital Western Kalinga District Hospital

Bontoc General Hospital Barlig District Hospital Besao District Hospital Paracelis District Hospital Luis Hora Memorial Regional Hospital Natonin Community Hospitals

* Above Packages to expire on December 31, 2013.

Premium Collection vs Benefit Availment, Jan. – September 2013

Collection Benefit Payment

P412,899,000 or 68% of the annual

collection target

P875,362,714.18 or 71%% of the annual budget for benefit

payment

2013 Annual Premium Target CollectionP603,084,000.00

2013 Annual Budget for Benefit PaymentP603,084,000.00

PFPR Paid to Different Hospitals as November 19, 2013Province/Hospital Amount Released

Abra

1. Bucay Municipal Hospital P16,400.00

2. Dolores Medicare and Community Hospital P41,600.00

3. La Paz District Hospital P65,459.86

Apayao

1. Far North Luzon Gen. Hospital & Training Center P123,000.00

Kalinga

1. Kalinga Provincial Hospital P258,500.00

2. Juan M. Duyan District Hospital P181,500.0

3. Kalinga District Hospital P172,000.00

4. Pinukpuk District Hospital P222,500.00

5. Western Kalinga District Hospital P176,250.00

PFPR Paid to Different Hospitals as November 19, 2013

Province/Hospital Amount Released

Mt. Province

1. Bontoc General Hospital P958,760.00

2. Barlig District Hospital P115,784.51

3. Besao District Hospital P351,636.67

4. Paracelis District Hospital P14,250.00

5. Luis Hora Memorial Regional Hospital P9,250.00

Grand Total P2,706,891.31

15

No. of Families Premium @ P2,400

DSWD Poor(Submitted for 2014 GAA)

Principal Families 5.48 million PhP 13.15 billion

Other families in the list 4.74 million PhP 11.38 billion

TOTAL 10.22 million PhP 24.53 billion

No. of Families Premium @ P2,400

DSWD Near Poor

Principal Families 2.41 million PhP 5.78 billion

Other families in the list* 2.08 million PhP4.99 billion

TOTAL 4.49 million PhP 10.77 billion

PAMANA and BANGSAMORO 17, 500 Php

42.00 million

Grand Total14.72

millionPhP 35.34 billion

(35,337,657,600)

Funding Requirements to Cover the Poor and Near Poor

16

Funding Requirements to Cover the Poor and Near Poor

EXPANDED COVERAGE as Stated in RA 10606Enroll the remaining vulnerable groupsWomen about to give birth (and as determined by means test recognized by DSWD) (Sec 21, RA 10606)

Barangay health workers, nutrition scholars, and other volunteer workers of the LGU. (Sec 20, RA 10606)

Workers rendering services in government offices such as job order, project-based contractors, and the like (paragraph 3, Sec. 5, Rule I, Title III of the IRR of RA 10606)

Require PhilHealth membershipMake PhilHealth membership a mandatory requirement for doing business or issuing professional or business license or permit like (paragraph 3, Sec. 6 of RA 10606)

Point of CareCover the unenrolled poor and protect them from the financial risks of ill-health at point of care.

Outcome 2: Financial Risk Protection

Strategy 2: Improve Benefit PackageAction Status TARGETS

2014 2015 2016

1. Implement No-Balance Billing

LGUs: 6%

DOH: 11%

15

50

35

80

50

90

2. Increase access to primary Care Benefit Package

5.4 M NHTS Families

14.7 M* 14.7 M 14.7 M

3. Implement Case Rates to all conditions

12 Surgical 11 Medical Conditions

All surgical and medical conditions

4. Expand Catastrophic Care Package (Type Z)

8 conditions 12 20 25

* Depends on NHTS list of DSWD

Preventive and curative care

Ensure No-Balance Billing (NBB) implementation - No other out-of-pocket expenses will be charged from sponsored members confined in government facilities beyond the prescribed benefit package rates of PhilHealth.

Primary Care Benefit I – diagnostic examination including complete blood count, urinalysis, fecalysis, sputum microscopy, fasting blood sugar, lipid profile, chest x-ray and primary preventive services

Primary Care Benefit II – outpatient medication for hypertension, diabetes and dyslipidemia

Special Benefit Packages – TB treatment through DOTS, Maternity Care Package, Malaria Treatment, HIV/ AIDS treatment, Animal Bites

Z-Benefit Packages – health packages for catastrophic conditions

Implementation of All Case rate payments as a more efficient provider payment mechanism.

IMPROVED BENEFIT PACKAGE

Continuing PhilHealth Efforts and Activities in the Hospitals

• Deployment of PhilHealth Customer Assistance Relations Empowerment Staff (PCARES)

• Best Efforts to reduce turn-around time in processing claims. (CAR is the 3rd place nationwide - fastest TAT in claims processing, 2012)

• Priority Lane for NBB Claims through the Reg Tag Corner

• Study/Survey Regarding Membership Status of Patients Admitted in Hospitals

• “The Benguet General Hospital Project” – Iwas RTH

Planned Activities For 2013 and Beyond

• Point of Care Engagement of Hospitals• Increase Hospitals Implementing NBB • Orientation of the ACR by Province starting 4th

week of November 2013• Expansion of Study/Survey on Membership

Status of Admitted Patients in Private Hospitals