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Leizel P Lagrada MD MPH PhD
Advancing Partnerships for Universal Health Coverage/July 8, 2015
Integrating Private Providers with National Insurance Schemes: Insights from the Philippines
Philippine National Health Insurance Program
Mandate Provide all citizens with the mechanism to gain financial access to health services RA 7875 (1995) as amended by RA 9241(2004) & RA 10606 (2013)
Coverage Compulsory coverage for all citizens; Family-based membership where primary member and qualified dependents have almost the same benefit
Administration Single-payer system
Financing • For employed: Payroll-based premium with employer and employee contributions (2.5% of basic salary)
• For Self-employed: Two-tiered annual premium PhP2,400 (US$54) with less than P25,000 (US$563.5) monthly
income) PhP3,600 (US$81) for those earning P25,000 or higher monthly income • Government subsidy for the poor and senior citizen (PhP2,400 annual
premium)
Philippine National Health Insurance Program
Benefits • Uniform in-patient package, including catastrophic benefit packages • Primary care benefit for the indigents and other sponsored members
(will also be rolled out to all members …)
Providers • Voluntary accreditation of government and private health facilities • Plus: contract with hospitals to deliver catastrophic benefit packages
Payment Mechanism
• Case rate for in-patient benefits • Special Case Rate for Z packages • Per Family Payment Rate (PFPR) for Primary Care Benefit (Tsekap)
Privileges • Automatic coverage of the poor assessed by NHTS-PR of the Department of Social Welfare and Development (DSWD)
• No Balance Billing for indigents and sponsored members when admitted in government hospitals
• Automatic availment of benefits by pregnant women and those enrolled as sponsored member at point-of-care
• Lifetime entitlement to senior citizens (60 years old and above)
Where are we right now?
17 REGIONAL O F F I C E S
106 L O C A L OFFICES
6,400 OFFICERS S T A F F
~100,000,000 F I L I P I N O S
Reaching more population over the years…
87% of the population covered by NHIP
(Based on 2014 projected population)
2010 2011 2012 2013 2014
Overseas Workers 6.9 5.09 5.23 5.86 1.83
Lifetime 0.85 0.95 1.25 1.32 5.95
Employed- Private 22.63 18.1 19.51 20.43 21.32
Employed- Government 6.58 5.9 6.43 5.91 5.72
IPP 10.92 9.91 11.82 11.99 5.56
Sponsored Program 22.1 38.45 36.68 31.38 45.84
0
10
20
30
40
50
60
70
80
90
100
Population with PhilHealth Coverage between 2010-2014 (in millions)
Participation of Private Sector in NHIP Implementation
Expanding Coverage Benefit Development
Service Delivery & Quality Assurance Information System
NHIP Goals
Private Sector in Expanding NHIP Coverage
Expanding Coverage Benefit Development
Service Delivery & Quality Assurance Information System
NHIP Goals
Private Sector in Expanding NHIP Coverage
As contributing members
25% of NHIP members are private employees
As collecting agents
41 private banks, 6 non-bank collecting companies; both local & international
As sponsoring institutions for near-poor not identified in NHTS-PR
Participation of Private Providers in NHIP Implementation
Population Coverage
Benefit Development
Service Delivery & Quality Assurance Quality Assurance
NHIP Goals
Private Providers’ Participation in
Designing PhilHealth Benefits
In setting clinical standards
Medical specialty societies contribute to the development and adoption of CPGs
In setting cost of care
Consultation with private sector in setting the case-based payments
negotiated the prices of medicines for Tsekap and Z-benefits
Private Providers’ Participation in
Service Delivery & Quality Assurance
Population Coverage
Benefit Development
Service Delivery & Quality Assurance Information System
NHIP Goals
Private providers’ contribution
to widen access to health care
Private providers have contributed to improving access to quality health care
Note: Primary care facility here includes clinics that provide PCB, TB DOTs, animal bite treatment. It does not include MCP providers. Source: PHIC Accreditation Department
642
2302
641
2361
668
3441
708
4118
738
4217
987
48
985
61
1046
61
1053
73
1088
101
Hospital & infirmary
Primary Care
Facility
Hospital & infirmary
Primary Care
Facility
Hospital & infirmary
Primary Care
Facility
Hospital & infirmary
Primary Care
Facility
Hospital & infirmary
Primary Care
Facility
2010 2011 2012 2013 2014
Accredited Health Care Facilities, 2010-2014
Government Private
Moreover, increase access to maternal care is possible through private birthing clinics
About 50% of Maternal Care Package are provided by private clinics
increasing number on accredited midwives indicates more skilled birth attendance
286
461
698 780
1320
464 609
778 816
1325
2010 2011 2012 2013 2014
Accredited Birthing Facilities (MCP Providers)
Government Private
35 66 87 141 147 235 355 354
518
824
1195
2159
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Accredited Midwives, 2003-2014
Accredited Midwife
Process of engaging private providers
Secure DOH License to operate
Apply for PhilHealth
Basic Accreditation
Coming soon: Application for
Advance Accreditation
Who and how to apply for basic accreditation
Who may apply?
• Health care institutions • Hospitals • Infirmaries • Primary care clinics
• Maternity care clinics
• Ambulatory surgical clinics
• Dialysis clinics • Pharmacies
Who may apply?
• Health professionals • Doctors: GP, specialists
• Dentists • Midwives
Requirements for Basic Accreditation
• DOH license, or equivalent
• Signed Performance Commitment (Warranty of Accreditation)
• Provider Data Record • Accreditation Fee • …etc
Private providers in quality assurance: Quality Assurance Committee
Committee Composition Chaired by PhilHealth (SVP for Health Finance Policy) Members include representatives from medical specialty societies, Philippine Regulatory Commission and hospital association
Provides PhilHealth technical advice on Health provider performance monitoring Assessment of quality of care provided to PhilHealth members
Adoption of CPGs and other tools to promote quality of care Issues related to provider payment scheme for surgical and non-surgical procedures
Participation of Private Providers in NHIP Implementation
Population Coverage
Benefit Development
Service Delivery & Quality Assurance Information System
NHIP Goals
Private providers in PhilHealth’s IT
system: Tsekap IT Flow The IT Flow involves data
management and transactions related to enlistment, eligibility validation, profiling, diagnostic services, prescription-dispensing, capitation calculation and payment, and mandatory-performance reporting
ePresciption was developed and tested with private drug store
Electronic Medical Record (EMR) providers are mostly private-owned
90% of primary care providers with Tsekap IT system are supported by private IT companies
Note: There are other PhilHealth PPP endeavors on IT, with varying results
Participation of Private Providers in NHIP Challenges
• Monitoring the quality of care provided by private health facilities
• Addressing and controlling fraudulent claims
• Updating private partners on NHIP policies
• Engaging private practitioners to empower PhilHealth members O
pportunities
• Willingness of the private providers to participate
• Leveraging PhilHealth payment to encourage private sector in hard-to-reach areas or provide public health services
• Wider benefit packages that are attractive for private sector to deliver
