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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
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)
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
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