updates on the 23 case rates and the all case rates … ac lectures/may 5/for pcp...23 case rates...
TRANSCRIPT
Updates on the 23 Case Rates and the
All Case Rates Initiatives
Utilization Review of Case Rates
Sept 2011 to May 2012
Utilization Review of Case Rates•The total volume of claims based on date of admission for all the case rate conditions covering all membership types is 2,150,857• Of the total claims filed (including FFS), 46% are under case rate•Of the total case rate claims, 43% are under medical conditions and the highest number of claims are Pneumonia cases•57% came from surgical conditions and the highest number of claims are Hemodialysis cases•Most case rate claims were availed by members from the employed sector
0
50000
100000
150000
200000
250000
300000
350000
num
ber o
f cla
ims
Overall Utilization of Medical Case Ratesby Membership Type, Sept 2011 to May 2012
OWP
Lifetime
IPP
Employed
Sponsored0
100000
200000
300000
400000
500000
600000
num
ber o
f cla
ims
Overall Utilization of Surgical Case Ratesby Membership Type, Sept 2011 to May 2012
OWP
Lifetime
IPP
Employed
Sponsored
Utilization Review of Case Rates•There is an average 3% decrease in the availment of Medical Case Rates from Sept 2011 to May 2012•However, in the same period, there is an average 5% increase in the availment of Surgical Case Rate conditions
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Sep Oct Nov Dec Jan Feb Mar Apr May
2011 2012
num
ber o
f cla
ims
Utilization of Medical Case RatesSept 2011 to May 2012
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Sep Oct Nov Dec Jan Feb Mar Apr May
2011 2012
num
ber o
f cla
ims
Utilization of Surgical Case RatesSept 2011 to May 2012
Comparative Review of Case Rate Conditions
•Comparing utilization of similar condition with the Sept ‘09 to May ’10 under FFS, Pneumonia and Hemodialysis topped the cause of admission for medical and surgical, respectively• A significant increase in the volume of claims for Hemodialysis was noted (150%)
0
50000
100000
150000
200000
250000
300000
350000
num
ber o
f cla
ims
Comparison of Volume of Claims for Medical Conditions, FFS vs.Case Rates
FFSSept 09toMay 10
CRSept 11toMay 12
0
100000
200000
300000
400000
500000
600000
num
ber o
f cla
ims
Comparison of Volume of Claims for Surgical Conditions, FFS vs.Case Rates
FFSSept 09toMay 10
CRSept 11toMay 12
Review of Case Rates
• Improved turn-around time from >70 days to 45-50 days for Case Rate claims
• Introduced the No Balance Billing Policy for Sponsored Program members • However only 15% surveyed are true NBB.
• World Bank’s study on Costing – local government hospitals gained. DOH hospitals either are break even or lost.
FFS Partial Case Rates
All Case Rates
Advantageous to PhilHealthContain the excesses of HCPs without sacrificing support to membersImprove turn-around-timeMake the benefits easier to communicateAllow PhilHealth to introduce incentives and NBBImprove transparency and predictability i.e. members know their benefitsPush health care providers toward better efficiency
All Case Rates Policy
Conceptual Framework
Fee for Service Case Rates
Incentive for efficiency Incentive for quality
Equitable distribution of reimbursement and
better resource management
Critical Step in the Creation and
development of a policy and regulatory
environment for Financial Risk Protection
Co-pay policies and No Balance billing
Outcomes-basedFacilities enhancements
2010 Premium Payment 29.087 Billion
Benefit payment 30.513 Billion
No of claims 3,479,453 Total benefit payment(in million pesos)
30,513.1
Total benefit payments for drugs and medicines
29%(PHP 8,848,794,079)
For the first time in the history of the NHIP, PhilHealth paid more in benefits than it collected in premium contributions: a difference of 1.5 billion pesos.
Benefit Payment 2010
Medicines comprise about 29% of the total amount paid by PhilHealth amounting to PHP 9B
• Messages• Case Rates and NBB are related but are different
concepts.• Case rates apply to all. NBB only for the
sponsored in government wards.• NBB patients are those that used to not afford to
pay but now will be able to through PhilHealth. (new markets)
• Currently, for non-sponsored member types, there is co-pay. But co-pay is not fixed to the detriment of the “next poor”.
Message to Providers
• stable claims• no fraud/up casing
PROCESS:
Methodology
COSTING•Using 2 sets of codes:
•ICD 10 for medical conditions•RVS for procedures•ISSUES
GROUPING•Conditions and procedures of similar nature and management were grouped together
Method
AVPC of all ICD 10 codes + 20% of the AVPC
Comparison with existing case rates,
PF study, actual rates in database
Medical Case Rates
• Why AVPC?• Source of available data is PHIC dbase• No fair costing studies on PF and hospital charges
Surgical Case Rates
Method
RVU Computation ProfessionalFee Facility Fee
RVU < 200 A (RVU x 56 x 1.5)/0.4
40% of A 60% of A
RVU 200 –300
0.8 x A = B (RVU x 56 x 1.5)/0.5
50% of B 50% of B
RVU > 300 0.67 x A = C (RVU x 56 x 1.5)/0.6
60% of C 40% of C
RVU-based rates (A)= (RVU x 56 x1.5) /0.4
• Why RVU?• To make PF rate Commensurate to the level expertise of doctors and receive
what they used to get from PHIC
Method1. Conditions and procedures of similar nature and management were
grouped together2. Review of grouping
a. Objective: to validate the ICD codes within the group and rates of the group; to determine if effect of proposed policies to the grouping and vice versa;
b. Initial review: 65 groups make up 85% of conditions claimsc. Still for review: 110 procedures comprise 90% of all procedure claims
3. Specialty societies were asked to submit a list of their most commonly claimed conditions and procedures (7 societies out of 22 replied so far)
4. Comparison of IPT proposed rates with rates from specialty societies5. Consultation with societies to verify/validate groups and identify
admissions criteria6. Adjust groups and rates based on consultation7. Actuarial evaluation and projection on proposed case rates
• Why these methodologies?• We need extensive researches such as a
transparent Professional Fee Study and accurate government costing for basic quality services for the poor but we cannot do this immediately.
• But we need to go all case rates in order to sustain the gains, improve financial protection through equitable payments, and improve the understanding of our members on their benefits
Case Rate Averages and Messages
• Messages• Case Rates and NBB are related but are different
concepts.• Case rates apply to all. NBB only for the
sponsored in government wards.• NBB patients are those that used to not afford to
pay but now will be able to through PhilHealth. (new markets)
• Currently, for non-sponsored member types, there is co-pay. But co-pay is not fixed to the detriment of the “next poor”.
Message to Providers
COMBINATION OF RATES
100% Main
Condition
% for the other
conditions
Combination of Medical Case Rates
100% Main Condition/ Primary case rate
% of Secondary Case Rate
Combination of Medical & Surgical Case
Rates
100% Primary Case
Rate
% for the other surgical
case rates
Procedures done in one
operative session. One
incision
100% Primary Case
Rate
%Secondary Case Rate
One operative session, multiple incisions
100% Primary Case
Rate
%Secondary Case Rate
Different operative
sessions, one confinement
Thank You