Social Health Insurance

in the Philippines

Jane M.N. Sta. Ana, R.N. Member, Board of Directors

Philippine Health Insurance Corporation

Draws inspiration from the Filipino trait of

“bayanihan” or social solidarity

*Artwork by Filipino National Artist

Carlos "Botong" Francisco

Started from the government’s desire to provide its people with

access to effective medical care services

at an affordable price

1972 – Medical Care Act - the country’s first attempt at universal social health insurance

1995 – National Health Insurance Act - mandate of PhilHealth is to provide universal social health insurance coverage

The law has been subsequently amended in 2004 through

Republic Act 9241 and in 2013 through Republic Act 10606.

History of NHIP

Every Filipino is a member, Every member is financially-risk protected,

Everyone’s health is assured.

Value-added benefits for every member,

Quality service for all.

Vision and Mission

88% of 2015

projected population

Note:

- Indigent count of members and dependents was based on DSWD Listahan database and are subject for further validation.

- 2015 Projected Population is 101,449,681 based on May 2010 Census by NSO.

Sector Members Dependents Beneficiaries

Members in the Formal Economy

13,368,671

14,204,553

27,573,224

Private

11,326,505

10,377,566

21,704,071

Government

1,982,042

3,782,546

5,764,588

Household Help/Kasambahay

59,482

43,421

102,903

Enterprise Owner & Family Drivers 642

1,020

1,662

Members in the Informal Economy

3,602,640

4,163,236

7,765,876

Migrant Worker

1,086,439

976,336

2,062,775

Informal Sector

2,107,443

2,702,689

4,810,132

Self-Earning Individual

396,898

471,890

868,788

Organized Group and Others 11,860

12,321

24,181

Indigents

15,288,583

30,118,509

45,407,092

Sponsored Members

489,730

647,921

1,137,651

Senior Citizens

4,813,460

1,068,411

5,881,871

Lifetime Members

955,850

696,157

1,652,007

Covered Members and Dependents (as of June 2015)

Contributions

Premium Contribution

o Formal Sector – income base (2.5% of the salary, equally shared by the employer and employee, subject to a salary cap)

o Indigents - premium of P2,400 per year coming from proceeds of the Sin Tax

o Informal Sector – premium is set at P2,400 per year; this sector includes Overseas Filipino Workers (OFWs)

o Lifetime members - entitled to lifetime coverage without having to pay additional premiums. Automatic coverage for all senior citizens (but those employed, would still have to continue with premium payments)

Overseas Workers

Eligible to avail of the benefits on the day of enrollment (no waiting period)

Member and his / her dependents in the Philippines can avail of the benefits

After expiry of membership, member has one (1) month grace period to ensure there is no gap in membership

Senior Citizens

All seniors are automatically covered in PhilHealth

The Office of the Senior Citizens Affairs (OSCA) for each city and municipality issues an electronic list of senior citizens and they are automatically enrolled as PhilHealth members. Senior citizens can also apply directly to PhilHealth with any proof of their age

Members are immediately eligible to avail of the benefits

17 REGIONAL O F F I C E S

106 L O C A L OFFICES

6,400 OFFICERS S T A F F

P 55.46 B

2013

P 78.18 B

2014

P 48.6 B

June 2015

We paid P1.5 billion every week in 2014,

now we are paying P2 billion every

week

Type of Ownership Government Private Total

Accredited Facilities 742 1,105 1,847

Primary Care Benefit Package

Maternity Care Package DOTS Package

Number of Accredited Outpatient Clinics

2,253 2,381 1,546

99% of DOH-licensed hospitals are accredited by PhilHealth

Accredited Institutional Providers (as of June 2015)

Primary Care & MDGs

Case Rates Catastrophic

(Z benefits)

Primary Care Benefit Maternity Care Package Newborn Care Package

TB-DOTS Package Animal Bite Package

Malaria Package Outpatient HIV-AIDS Package

Acute Lymphocytic Leukemia Early Breast Cancer

Prostate Cancer Kidney Transplantation

Coronary Artery Bypass Graft Total Correction of TOF

Closure of VSD Cervical Cancer

Z Morph Peritoneal Dialysis

Inpatient cases Day surgeries Chemotherapy Radiotherapy Hemodialysis

Spectrum of PhilHealth Benefits

Provider Payment Mechanisms of

PhilHealth Then and Now...

Fee-for-Service

Implemented during the PMCC era carried over by PhilHealth

Health care providers are paid for every unit of service rendered

Reimbursement is dependent on case type and level of hospitals/ facility

Partial Case Rates (23 cases)

Implemented last September 2011

49% of the total claims

Bundled payment (HCI fee and PF)

Uniform rate across member category and type of hospital or per type of facility

All Case Rates (ACR)

Implemented last January 1, 2014

No balance billing. Indigent members would not be paying extra if

they are confined in service wards in government facilities.

Primary Care Benefit (PCB) Package. For Sponsored Members,

they receive a primary care package for basic laboratories and

consultations and would soon include medicines for select chronic

conditions.

Sulit ang Benepisyo sa PhilHealth

TSEKAP Preventive & Diagnostic Services

• Consultation • BP and Body Measurements • Breast Exam and Breastfeeding

Education • Prostatic CA Screening • Counselling for Smoking

Cessation and lifestyle

modification • Risk profiling for Hypertension

and Diabetes

• CBC

• Urinalysis

• Chest x-ray

• FBS

• Lipid Profile

• Creatinine

• ECG

• Blood glucose monitoring

TSEKAP Medicines

• Asthma: Salbutamol, Fluticasone, • URTI: Amoxicillin, Erythromycin, Paracetamol, Lagundi • Pneumonia: Amoxicillin, Erythromycin, Co-amoxyclav • UTI: Ofloxacin, Cotrimoxazole, Co-amoxyclav • Ischemic Heart Disease: Atenolol, Isosorbide Mononitrate • Diabetes: Gliclazide • Hypertension: Enalapril Amlodipine • Dyslipidemia: Simvastatin • Gout: Colchicine, Allopurinol

P1,000 cap per family

Surgical Procedures

1 Radiotherapy Linac ₱3,000.00

2 Radiotherapy Cobalt ₱2,000.00

3

Maternity Care Package (PCF, Birthing Homes) ₱8,000.00

Normal Spontaneous Delivery Package ₱6,500.00

(Levels 1-3 Hospitals)

4 Cesarean Section ₱19,000.00

5 Appendectomy ₱24,000.00

6 Newborn Care Package (Birthing Homes, PCF, Levels 1-3 ₱1,750.00

7 Dilatation & Curettage ₱11,000.00

8 Hemodialysis ₱4,000.00

9 Hysterectomy ₱30,000.00

10 Cataract Package ₱16,000.00

Top Surgical Case Rates

Top Medical Case Rates

Medical Conditions

1 Dengue Fever ₱10,000.00

2 Dengue, Severe ₱16,000.00

3 Pneumonia Moderate Risk ₱15,000.00

4 Pneumonia High Risk ₱32,000.00

5 Hypertensive Emergency / Urgency ₱9,000.00

6 Stroke - Infarction ₱28,000.00

7 Stroke - Hemorrhagic ₱38,000.00

8 Acute Gastroenteritis ₱6,000.00

9 Asthma in Acute Exacerbation ₱9,000.00

10 Typhoid Fever ₱10,000.00

Type Z Benefits

Pediatric

Leukemia P210,000

Breast Cancer P100,000

Prostate Cancer P100,000

End Stage Renal

Requiring Kidney

Transplant

P600,000

Coronary Artery

Bypass P550,000

Tetralogy of Fallot P320,000

Closure of

Ventricular Septal

Defect

P250,000

Cervical Cancer

Chemoradiation P175,000

Z Morph (lower limb

prostheses) P15,000

Type Z Benefits. PhilHealth provides substantial support for

conditions which normally are very expensive.

Working with Nurses

PhilHealth Customer Assistance,

Empowerment and Relations Staff

Working with Nurses

A Circular is currently being finalised that

would provide for the accreditation of nurses

as maternity care providers, antenatal care

and newborn packages

� Sustained coverage of the population in the

program;

� Increased financial risk protection that

contributes to poverty reduction; and

� Improved health outcomes through wider

access to health services and better benefits.

Key Priorities

Challenges

1. Health expenditure remains low – the Philippines

remain as a low spender on health compared to other regional

and middle income economies.

2. Out of pocket spending is still high – the rising cost of health care services largely contributes to the growing OOP spending.

3. Poverty incidence has not caught up with overall

improvements – the country’s poverty rate remained one of the highest in the region despite the decent economic growth.

4. Recurrent shocks from climate change are highly expected –

climate hazards are becoming a constant threat to the social and

environmental determinants of health.

www.philhealth.gov.ph