PhilHealth Engagement

Follow-through meeting30 October 2013

Philippine Rural Reconstruction Movement Building, Dr. Lazcano corner Mother Ignacia Avenue, Quezon City

 Agreements reached at our

September 27 Forum on PhilHealth

Agreements/ Resolutions:

1)      Civil Society volunteers to help out in information dissemination

After realizing that the members’ lack of knowledge and information about the PhilHealth is a huge contributing factor to why there is low utilization, the participants in the forum have accepted a role of helping PhilHealth in helping in information dissemination. They volunteered to translate relevant PhilHealth materials, which are always written in English, to the language which is more convenient to use by the general public. Aside from that, the group also asked for other materials such as those that could empower patients. (October 2013 meeting)

2)      The Civil Society is welcomed to attend the monthly ManCom

Dr. Shirley Domingo emphasized that what everyone wants is to improve the country’s health care system. And while she reiterated that doing so could not be done by PhilHealth alone, she recognized that the CSOs can play a role in a lot of ways. She, in the end of the event, accepted the suggestion of the participants which is to let CSOs attend the monthly ManCom (meetings attended by PhilHealth officers) to be able to further help especially in discussing policies.         

PHILHEALTH REGIONAL OFFICE NCR and RIZAL (PRO NCR and RIZAL) 

Office of the Vice President – Dr. Shirley DomingoPublic Relations Unit – Henry RamosHealth Care Delivery Management Division – Dr. Nenita ValbuenaInformation and TechnologyQuezon City – 52 hospitals

 PRO NCR AND RIZAL THREE BRANCHES:

PRO NCR South: Henry AlmanonLas Pinas, Makati, Muntinlupa, Pasay, Pasig, Pateros, Taguig, Parañaque

PRO NCR Central: Gilda Salvacion DiazQC, Marikina, San Juan

PRO NCR North: Dr. Elizabeth FernandezCaloocan, Mandaluyong, Manila, Navotas, Malabon Valenzuala

 PRO RIZALAngono, Antipolo , Baras, Binangonan, Cainta, Cardona, Jala-Jala, Morong, Pililla, Rodriguez, San Mateo, Tanay, Taytay, Teresa,

Local Health Insurance Office (Local Government) Business Processes: 1. Membership 2. Collection3. Claims4. Accreditation (hospitals, center, professionals)5. Marketing (LHIO)6. Legal7. Public relations unit8.. IT

PhilHealth Thrust: Financial Risk Protection

1. Satisfied and empowered beneficiaries and stakeholders

2. Excellent business processes

3. Viable, social health insurance fund

4. Adequate organizational capability

No Balance BillingConsiderations:

Sponsored program

Government hospital

25 case payments only

PhilHealth NCR IEC Planning Workshop

18-19 November, 2013

Membership Satisfaction. Increase awareness. Ensure access to healthcare service providers and professionals. increase collection. accurate -- operational excellence, strengthen relationship with stakeholders, cultivate shared understanding of philhealths corporate values. boost social marrketinga nd social satisfaction. ensure data quality of philhelaht data base.

Point of Service enrollment - - - former member just need to pay past 3 months premium, for indigent members - enrollment at point of service (pilot hospitals - Quirino, East Avenue Medical Centers) -- entitled to benefits into 3 mos - as needed

On Complaints: can request for motion for reconsideration for disapproved reimbursment == that overt act (statement) is already a request for motion for reconsideration (c/o Diaz, branch manager) opening for advocacy -- the mere resubmission is an act of reconsideration ---

magkaconchaba yung ospital at doctor na di accreditated - dapat ba sasabihin na senior citizen kahit obvious na - should they ask? what do we want? policy dapat pagpasok tatanungin agad yung patients

Benefit payment notice – we can ask what they charged – halimbawa doble ang sinigil na professional fee

Dapat bantayan yung charging ng providers - kasi they can overcharge - - we should request for benefit payment notice mula sa office ng PhilHealth

Public relations unit nandiyan lahat ng reklamo - gusto nila ngayong tingnan ang trends of complaints - complaints of members, hospitals, professionals - for policy implications

Benefit administrative Section is in charge of claims - sana may monitoring of complaints of members - we can complain if the serivce provider did not give us true benefits

we can also ask from their collection unit if our employer did not remit to PhilHealth

Pateros and Navotas do not have hospitals yet

Monitoring is our entry point - to see if the accredited service providers are providing the right payment

Can also monitor sponsored programs -- No Balance Billing

Primary care benefit/package - PhilHealth will provide capitation - for indigents and organized groups - covered Families are -- annual health profiling - primary care doctors visit at least once a year - not just during sickness

Monitor accredited hospitals: Post-monitoring scheme

Automatic accreditation of PhilHealth for DOH licensed government hospitals – ibig sabihin di na kailangan dumaan sa stringent process of PhilHealth accreditation for government hospitals basta licensed ng DOH

PCB - Primary Care Benefit package

-- advance benefit na yan - PhilHealth has already given capitation to the service providers

For now 25 case rates, baka later on lahat na ---

Statement of CHAT, KAMP, AER, ABI and WomanHealth Philippines during the Mancom

PhilHealth is not just Financial risk protection. It is an equity tool and poverty tool. Delivery of basic services such as education, health and housing (commons) is a strategy to address poverty.

Palagi niyong iniinterchange ang clients-customers- --- language is important – we are not clients or customers, we are members –

We also push for financing – wag niyong ihihiwalay ang corporation sa members

Bawat pilipino miyembre, kalusugan natin sigurado … sana ang bawat miyembro sasabihin – amin, atin – hindi lang sa inyo ang PhilHealth, amin yun, atin iyon- dahil atin ito gusto naming protektahan ito

Point of Service EnrolmentPregnant women

Covered for the fiscal year (i.e. until December of the same year)

Point of Service: Labas ng 2,400, kubra pabalik ay 8000

Indigency evaluation through DSWD for continued membership

Initially, PhilHealth accredited government hospitals

Higher rate for lying-in centers

Normal delivery

Next stepsPagkikita ng DSWD, PhilHealth at DOH

DATA

Unacceptable high OUT OF POCKET

Low level of public spending

2009 53.3% THE 26-27% of THE2010 52.5%2011 52.7% In terms of equity, it it the worst picture.It is the opposite of what we want to happen. 

Poverty incidence:

• no significant improvement, • 2003-2009 despite favourable economic growth,• 40 richest families• No inclusive growth; • increasing informal/contractual workers 

Frog leap investment 2010-2014

poor & near poor 14.7 million families; 50M individuals2011: 3.5B P 31.9 GAA2012: 12B P 42.2B2013: 12.6B P 53.1B

2014: 35.3 P 80.1 NEP (P30B increase, P23B goes to PhilHealth)NHIP – p35.3B 2014

2015: 35.3 P 88.62016: 35.3 P 89.5  

Innovative Financing

Sin Tax legislated in 2013. Earmarked for health

2013: P 28.8B2014: P 36.4B2015: P 43.035B2016: P 48.331B2017: P 54B

Challenges: Financial risk protection

No Balance Billing (NBB): • only 7% compliance to NBB policy (DOH hosp 11%, LGU hosp 6%). • 93% continued practicing BB• Not ready to apply NBB: lack of medicine, laboratory and supplies

Case rate payment not reflecting full cost• Expansion case payment from 23 to all conditions:• Payment rate based on formula which do not reflect full cost• May repeat mistake f noncompliance to NBB

Fundamental problems: not addressed adequately 1. Two decades stagnation: hospital bed population ratio2. Overstretched bed, inadequate essential, auxiliary services 3. Supply bottlenecks restrict people seeking care; one of the Reasons

for not accessing health care4. Decentralization: large regional gaps in Shelled Birth Attendant

(SBA)

Level 1-4 clinical laboratoryX-rayPharmarcyDental service

FLAGSHIP STRATEGY IStrategic Vision: Advancing population coverage with a PCB++ for all and gradually expand package to IP. 1. Rolling out a package of primary care service including curative, preventive, promotion services PCB1 and 2, to all PhilHealth members (not only the poor). 2. Rolling out a publically funded package of PCB1 and 2 ++ (++ aims to reduce OOP and gaining health, quite a comprehensive package) to all Filipinos who are PhilHealth members and the remaining uninsured. 3. NBB applied throughout to reduce OOP. 4. Assessment and declare UHC for a package of primary care for all Filipino.

FLAGSHIP STRATEGY IIStrategic Vision: Supply side strengthening (HRH, Facilities) 1. Heavy investment in a strong district health system (close to client services): RHU + DH to provide quality continuity of primary care services (Family Care, do not spend on tertiary care) 2. A decade of District Health Systems strengthening. 3. A five year plan for upgrading provincial, regional hospitals serving referral backups. 4. Devise policies to scale up, expand scope and financial / nonfinancial incentives of “mandatory district health services” by ALL medical nursing, pharmaceutical, dental graduates. 5. Embedded “rural retention” in education strategies (CHED, medical schools), rural recruitment, hometown placement, back to their hometown. 6. SUPPLY SIDE BOTTLENECK. 

ACTION POINTS: A. Mobilize more resources

1. Sin Tax2. GAA on top3. the ceiling of 35K for the payroll contribution be removed.

B. Improve efficiency1. Seek greater allocative efficiency, shifting resource to primary

care, increasing spending on preventive and health promoting interventions

2. Set right provider payment incentives- costing of service leading to care-based reimbursements of

inpatient care- gradual reduction of the DOH subsidies to the hospitals

and shifting resources from DOH budget to PhilHealthC. Monitoring and Feedback

1. Accredited Facilities and Professionals (PhilHealth)2. Sponsored Program is with DSWD – LGU identifies and

distributes cards

  

Principles of Civil Society Engagement