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PHILHEALTH UPDATESPHILHEALTH UPDATES22ndnd Semi-Annual Hospital Managers Meeting Semi-Annual Hospital Managers Meeting
OUTLINE OF PRESENTATION
I.PhilHealth Directions in Relation to KP Including Status of PhilHealth Membership, Collection and EngagementII.Implementing Rules and Regulations of RA 10606III.New PhilHealth ProgramsIV.Benefits Payment and AvailmentV.Open Forum
Atty. Jerry F. IbayRegional Vice PresidentPhilHealth-CAR
Synergy for Universal Health Care
KP Vision
Financial Risk Protection
Access to Improved Health Facilities
Attainment of Health-related MDG
Bawat Pilipino Miyembro
Bawat Miyembro Protektado
Kalusugan Natin Segurado
Outcomes and Strategies of UHC
Outcome 2: Financial Risk Protection
Strategy 1: Expand PhilHealth CoverageAction Status TARGETS
2014 2015 2016
1. Enroll NHTS poor & near-poor families
5.2 M 14.7 M* 14.7 M 14.7 M
2. Increase hospitals with point of care enrollment
LGU
DOH
100
72
200
72
300
72
3. Enroll the remaining informal sector
80%3.1M not
enrolled but can pay premium
85 88 90
* Depends on NHTS list of DSWD
84%
76%86%
Number and Percentage Distribution of Members and Dependents as of September 2013, CAR
2011 2012 2013LICENSED ENGAGED LICENSED ENGAGED LICENSED ENGAGED
ABRA 10 9 9 9 10 9APAYAO 7 7 7 7 7 7BAGUIO CITY 8 6 8 6 8 6BENGUET 9 9 9 9 9 9IFUGAO 8 8 8 8 8 8KALINGA 9 8 7 7 8 8MT. PROVINCE 7 7 7 7 7 7TOTAL 58 54 55 53 57 54
Summary of Licensed vs Accredited/Engaged Hospitals per province per year:
Hospitals With Out-Patient Benefit Package Services
OPB Services Province/City Hospital
TBDOTS BenguetBaguio City
Benguet Gen. Hospital (BeGH) Baguio Gen. Hospital & Medical Center (BGHMC) St. Louis Hospital of the Sacred Heart (SLUHSH) Notre Dame de Chartres Hospital
Hemodialysis BenguetBaguio City
BeGH BGHMC SLUHSH Notre Dame de Chartres Hospital Pines City Doctors’ Hospital
Animal Bite AbraKalinga
Mt. Province
Abra Provincial Hospital Kalinga Provincial Hospital Western Kalinga District Hospital Bontoc General Hospital Luis Hora Memorial Regional Hospital
Hospitals With Out-Patient Benefit Package Services
OPB Services Province/City Hospital
PCB Abra
Apayao
Baguio City
Abra Provincial Hospital
Bucay MunicipalHospital Dolores Medicare and Community Hospital La Paz District Hospital Villaviciosa Medicare and Community Hospital
Amma Jadsac District Hospital Flora District Hospital Sta. Marcela Med. and Community Hospital Far North Luzon Gen. Hosp. & Trng. Center
Baguio Gen. Hospital and Medical Center
Hospitals With Out-Patient Benefit Package Services
Province/City Hospital
PCB Kalinga
Mt. Province
Kalinga Provincial Hospital Juan M. Duyan District Hospital Kalinga District Hospital Pinukpuk District Hospital Western Kalinga District Hospital
Bontoc General Hospital Barlig District Hospital Besao District Hospital Paracelis District Hospital Luis Hora Memorial Regional Hospital Natonin Community Hospitals
* Above Packages to expire on December 31, 2013.
Premium Collection vs Benefit Availment, Jan. – September 2013
Collection Benefit Payment
P412,899,000 or 68% of the annual
collection target
P875,362,714.18 or 71%% of the annual budget for benefit
payment
2013 Annual Premium Target CollectionP603,084,000.00
2013 Annual Budget for Benefit PaymentP603,084,000.00
PFPR Paid to Different Hospitals as November 19, 2013Province/Hospital Amount Released
Abra
1. Bucay Municipal Hospital P16,400.00
2. Dolores Medicare and Community Hospital P41,600.00
3. La Paz District Hospital P65,459.86
Apayao
1. Far North Luzon Gen. Hospital & Training Center P123,000.00
Kalinga
1. Kalinga Provincial Hospital P258,500.00
2. Juan M. Duyan District Hospital P181,500.0
3. Kalinga District Hospital P172,000.00
4. Pinukpuk District Hospital P222,500.00
5. Western Kalinga District Hospital P176,250.00
PFPR Paid to Different Hospitals as November 19, 2013
Province/Hospital Amount Released
Mt. Province
1. Bontoc General Hospital P958,760.00
2. Barlig District Hospital P115,784.51
3. Besao District Hospital P351,636.67
4. Paracelis District Hospital P14,250.00
5. Luis Hora Memorial Regional Hospital P9,250.00
Grand Total P2,706,891.31
15
No. of Families Premium @ P2,400
DSWD Poor(Submitted for 2014 GAA)
Principal Families 5.48 million PhP 13.15 billion
Other families in the list 4.74 million PhP 11.38 billion
TOTAL 10.22 million PhP 24.53 billion
No. of Families Premium @ P2,400
DSWD Near Poor
Principal Families 2.41 million PhP 5.78 billion
Other families in the list* 2.08 million PhP4.99 billion
TOTAL 4.49 million PhP 10.77 billion
PAMANA and BANGSAMORO 17, 500 Php
42.00 million
Grand Total14.72
millionPhP 35.34 billion
(35,337,657,600)
Funding Requirements to Cover the Poor and Near Poor
16
Funding Requirements to Cover the Poor and Near Poor
EXPANDED COVERAGE as Stated in RA 10606Enroll the remaining vulnerable groupsWomen about to give birth (and as determined by means test recognized by DSWD) (Sec 21, RA 10606)
Barangay health workers, nutrition scholars, and other volunteer workers of the LGU. (Sec 20, RA 10606)
Workers rendering services in government offices such as job order, project-based contractors, and the like (paragraph 3, Sec. 5, Rule I, Title III of the IRR of RA 10606)
Require PhilHealth membershipMake PhilHealth membership a mandatory requirement for doing business or issuing professional or business license or permit like (paragraph 3, Sec. 6 of RA 10606)
Point of CareCover the unenrolled poor and protect them from the financial risks of ill-health at point of care.
Outcome 2: Financial Risk Protection
Strategy 2: Improve Benefit PackageAction Status TARGETS
2014 2015 2016
1. Implement No-Balance Billing
LGUs: 6%
DOH: 11%
15
50
35
80
50
90
2. Increase access to primary Care Benefit Package
5.4 M NHTS Families
14.7 M* 14.7 M 14.7 M
3. Implement Case Rates to all conditions
12 Surgical 11 Medical Conditions
All surgical and medical conditions
4. Expand Catastrophic Care Package (Type Z)
8 conditions 12 20 25
* Depends on NHTS list of DSWD
Preventive and curative care
Ensure No-Balance Billing (NBB) implementation - No other out-of-pocket expenses will be charged from sponsored members confined in government facilities beyond the prescribed benefit package rates of PhilHealth.
Primary Care Benefit I – diagnostic examination including complete blood count, urinalysis, fecalysis, sputum microscopy, fasting blood sugar, lipid profile, chest x-ray and primary preventive services
Primary Care Benefit II – outpatient medication for hypertension, diabetes and dyslipidemia
Special Benefit Packages – TB treatment through DOTS, Maternity Care Package, Malaria Treatment, HIV/ AIDS treatment, Animal Bites
Z-Benefit Packages – health packages for catastrophic conditions
Implementation of All Case rate payments as a more efficient provider payment mechanism.
IMPROVED BENEFIT PACKAGE
Continuing PhilHealth Efforts and Activities in the Hospitals
• Deployment of PhilHealth Customer Assistance Relations Empowerment Staff (PCARES)
• Best Efforts to reduce turn-around time in processing claims. (CAR is the 3rd place nationwide - fastest TAT in claims processing, 2012)
• Priority Lane for NBB Claims through the Reg Tag Corner
• Study/Survey Regarding Membership Status of Patients Admitted in Hospitals
• “The Benguet General Hospital Project” – Iwas RTH
Planned Activities For 2013 and Beyond
• Point of Care Engagement of Hospitals• Increase Hospitals Implementing NBB • Orientation of the ACR by Province starting 4th
week of November 2013• Expansion of Study/Survey on Membership
Status of Admitted Patients in Private Hospitals