PhilHealth: Perfecting the system

to produce better outcomes

Plugging the Holes for a Wider Benefit

Anthony Leachon, MD, FPCP, FACP

Independent Director
Representative of the Monetary Board
Outline

1. PhilHealth mandate, mission and vision

2. History and Milestones
3. Types of membership
4. Membership coverage
5. Benefits and benefit pay-out
6. Successes and landmarks
7. Challenges and opportunities
8. Call to action
PhilHealth
 Single Fund/Single Payor

 Draws inspiration from

concept of ‘bayanihan’

 Coverage of about 92%*

percent of population

 GOCC

 Offshoot of Medicare
*Artwork by Filipino National Artist
* As of Nov. 2015
Carlos "Botong" Francisco
Vision and Mission
History and Major Milestones
2013
1995
1969
1963
1962
Bawat Pilipino, MIYEMBRO

Formal Informal Sponsored Indigent Lifetime Senior

Economy Economy Members Members Members Citizen
Covered beneficiaries by Sector

Source: PhilHealth Stats and Charts, 2015

Bawat
MIYEMBRO,
protektado
Benefit payment

2013 – less than P1.1B a week

2014 – less than P1.5B a week
2015 – less than P1.9B a week

Source: PhilHealth Stats and Charts

PhilHealth Successes, Landmarks
 92% Much gains have happened…
Coverage
Z benefits &
NBB in public hospitals Passage of
for indigents RH Law
Enabling environment
> Php 200B combined for access & Strengthened food
resources compliance and drug
regulations
Health facilities
upgrading Increasing
Sin taxes for LGU success
health stories

Expanded free Health worker

medicines and deployment
vaccines programs

Slide courtesy of Dr. Beverly Ho, DOH, 2016

But many areas still require more
work for it to be felt by all
Focus on curative care

56% 3X Disparity between wealthiest

and poorest quintile
OOP at all-time
high NATIONAL IMR 23/1,000

Quality and safety are

not assured
WEALTHIEST
POOREST
13/1,000
36/1,000
~60% NBB compliance

Poor referral system

Not that responsive

Slide courtesy of Dr. Beverly Ho, DOH, 2016

The top conditions paid by PhilHealth do not match priority
health conditions and are focused on costly interventions

TOP 10 Medical Cases TOP 10 Procedures

1.Pneumonia
2.AGE
3.UTI
4.Dengue with warning signs
5.Bronchial asthma with exacerbation
6.Dengue without warning signs
7.Hypertension, stage II
8.Essential hypertension
9.Bacterial sepsis of newborn
10.Other acute gastritis
Source: PhilHealth Stats
and Charts, 2015
1.Hemodialysis
2.Newborn care package
3.Routine obstetric care including antepartum,
vaginal delivery and/or post partum NSD
(hospitals)
4.Routine obstetric care including perinatal
delivery and newborn services MCP (non-
hospital facilities)
5.Cataract removal
6.CS, primary
7.CS delivery
8.Radiation treatment delivery
9.Vaginal delivery only
10.Chemotherapy
TOP 10 Causes of Mortality TOP 10 Causes of Morbidity
1.Diseases of the heart 1.Acute respiratory infection
2.Diseases of the vascular system 2.Acute lower respiratory tract
3.Malignant neoplasms infection and pneumonia
4.Pneumonia 3.Bronchitis/bronchiolitis
5.Accidents 4.Hypertension
6.TB, all forms 5.Acute watery diarrhea
7.Chronic lung disease 6.Influenza
8.DM 7.UTI
9.Nephritis/ nephrotic syndrome/8.TB
nephrosis 9.Injuries
10.Perinatal disease 10.Diseases of the heart

Source: DOH, 2010

And from the patient’s perspective, UHC is unclear

Aling mga Mayor

serbisyo ang Sa private nalang kasi
PhilHealth
libre? malinis at kumpleto
ang gamit...di bale na Ewan! DOH
Saan ako Sakit sa
pupunta mamumulubi.. Asahan mo
tiyan, e di sa
kung may na ang BILL
gastro!
sakit? SHOCK!
PCSO Uutang
Hindi nalang
Magkano malinaw.
kaya aabutin .
ng bill?

Saan ako
makakahingi
ng tulong?

Slide courtesy of Dr. Beverly Ho, DOH, 2016

A glimpse on the vision of PhilHealth benefits

Slide courtesy of PhilHealth & Epimetrics, 2016

Call to Action
• Improve reimbursement policies based on evidence –
CPGs and standards
• Put rigor in the process
• While NBB for indigents is strictly imposed, DOH
and LGUs should improve supply side
• Introduce maximum copay for other members
• Improve primary care to prevent inpatient care and
costly interventions
• Develop systematic and evidence-based Benefit Plan
Perfecting the system through policy
• Pre-authorization for cataract and Z benefits
• Installed controls in reimbursement based on CPGs
(e.g. Length of stay for pneumonia, UTI and AGE)
• Strengthen HCP Performance Assessment System to
ensure quality of care, financial risk protection, patient
satisfaction and fraud prevention
• Put rigor in the process through reinstatement of SOA
• Work towards pre-payment medical audit
• Use of data analytics to understand provider and
population behavior
Priority setting initiative
Review of Focus Group Round Table Discussion
Literature Discussions with Experts

Public Health
Evidence Based
Medicine
Ethics
Quality
Health Policy
Thailand Australia UK Chile Health
Economics
Epidemiology
Law
Slide courtesy of PhilHealth & Epimetrics, 2016
Slide courtesy of PhilHealth & Epimetrics, 2016
Proposed Priority Setting Principles

Inclusiveness and Transparency

Ethical Soundness Preferential Regard Scientific and
Rigor Accountability
to the Underserved

Availability of
Efficiency Enforceability Remedies and Due
Process

Slide courtesy of PhilHealth & Epimetrics, 2016

Proposed Priority Setting Steps

1Nomination of
2
Shortlisting of
3 Generation of
Interventions Interventions Evidence

4 Appraisal of
5
Approval for
6 Approval for
Evidence Coverage Implementation

Slide courtesy of PhilHealth & Epimetrics, 2016

Proposed Criteria

Magnitude and Household

Severity with Equity Effectiveness Financial
Component Impact

Cost Implications
Cost Effectiveness to the Health
Sector

Slide courtesy of PhilHealth & Epimetrics, 2016

“If we keep doing what we have been doing,
we’ll keep getting what we’ve always
gotten.”

-Dr. Paul Batalden, Institute for Healthcare

Improvement
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