Asia Pacific Summit on Health Insurance and Managed Care Jakarta Indonesia May 2225, 2002

1
Asia Pacific Summit on Health Insurance and
Managed CareJakarta Indonesia May 22-25, 2002

• National Health Insurance Program, Philippines
• Presentation
• by
• Mr. Manolito A. Novales
• Dr. Maria Ofelia O. Alcantara
• Philippine Health Insurance Corporation

2
The National Health Insurance Program
thePhilippines
PhilHealth Healing the Wounds of Poverty
3
Infant Mortality and Under-Five
MortalityPHILIPPINES, 1978-1998
1998 NDS (1994-98)
1983 NDS (1979-83)
1988 NDS (1984-88)
1993 NDS (1989-93)
1978 RPFS (1974-78)
4
(No Transcript)
5
Maternal Mortality Rate172/100,000
6
Share of health expenditure to GNP lowest in 5
years
3.25
7
Health spending pattern remains unchanged
Personal 75.2
Personal 73.8
8
(No Transcript)
9
Notable increase in social insurances share in
health expenditure
51.8
55.2
7.1
5.1
39.7
41.1
10
Where does money for health come from?
Total Health Expenditure in 1999 114 B
Pesos or 3.61 of GNP
11
The Health Sector Reform Agenda

• Public health programs
• Local health systems
• Hospital facilities
• Health regulations
• Social health insurance

12
Health Sector Reform Agenda
Health Insurance
Hospital
Public Health Program
HSRA
Local Health Systems
Health Regulation
13
HISTORY of the Philippine Health Insurance Program
14
HISTORY of the Philippine Health Insurance Program
15
CONSTITUTIONAL MANDATES

• The State shall adopt an integrated and
  comprehensive approach to health development
  which shall endeavor to make essential goods,
  health and other social services available to all
  people at affordable cost.
  
• Priority to the needs of the underprivileged,
  sick,elderly, disabled, women and children shall
  be recognized. x x x (Section II, Article
  XIII of the 1987 Constitution)

• Likewise, the Philippine Constitution mandates
  DECENTRALIZATION and DEVOLUTION of health
  services to local government units(LGUs)
  (Section 25,
  Article II of the 1987 Constitution)

16
NHIP is...

• Administered by the Philippine Health Insurance
  Corporation (PhilHealth)
• It is a social health insurance program

17
PHILHEALTH MANDATE
Provision of Medicare Coverage to the
Poor (Section 29, RA 7875)
?
?
?
?
The Indigent Program, or Medicare para sa Masa,
is the component of NHIP which seeks to provide
free Medicare coverage to the marginalized
segment of the Filipino population.
Formal Sector
Informal Sector
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
Indigent Sector
?
?
?
?
The program is implemented through the
collaboration of Local Government Units (LGUs)
and PhilHealth.
18
DEPENDENTS

• Legal spouse
• Children (whether illegitimate, adopted or step
  children)
• Parents 60 years old and above

19
Individually Paying Program

• Covering the most difficult sector of the
  population
• Has moving target because of economic situation

20
Indigent Program

• Heart of NHIP
• Premium is shared by the local and national
  government
• Target coverage 25 of poorest of the
  poor

21
ENHANCED LGU MEDICARE PROGRAM
Conceptual Framework
LGU
PhilHealth
PREMIUM CONTRIBUTION
22
Creation of PhilHealth Capitation Fund
Phase 1
18
PHILHEALTH
6
Phase 2
LGU
PHILHEALTH CAPITATION FUND

• Provide Free
• Primary consults with Physicians
• Laboratory Examinations
• - Chest X-ray - Sputum Microscopy
• - Urinalysis - Complete Blood Count
• - Fecalysis
• Preventive Services

• PNDF medicines
• Equipment and supplies
• 20 admin. cost

Accredited Health Centers
23
Financing Framework
24
842 families or 3,873 beneficiaries
Assumption Ave. Value per Claim - US134 per
case
US 506 capitation fund
25
State of National Health Insurance Program

• Compared to targets, relatively slow expansion
  of
• Benefit spending
• Membership base
• Admin infra still being developed
• Inadequacies within the health sector affect
  program expansion
• Favorable public opinion on NHIP but information
  is still insufficient
• Unqualified support from the national leadership

26
Program Imperatives

• Benefit enhancements
• Universal coverage
• Priority for the indigents and other uncovered
  individuals
• Improvement of Admin infrastructure

HSRA Goals
27
What we have done

• Improvement of NHIP benefits
• Since 1995, inpatient ceilings increased thrice
• January 2002 increased ceilings for drugs and
  medicines by 35 and for x-ray and labs by 43
• Introduction of Outpatient Diagnostic Package in
  selected areas to members of the Indigent Program

28
The Outpatient Diagnostic Package
Phase 2
- Preventive Care
Phase 1
- Curative Care

• REGULAR INPATIENT AND OUTPATIENT BENEFITS
• Room and Board
• Drugs Medicine
• X-ray, Laboratory
• Professional Fees
• Operating Room, Surgeons
• Fees,Anesthesiologist
• Regular outpatient services

• OUTPATIENT CONSULTATION AND DIAGNOSTIC PACKAGE
• Primary consults
• Laboratory fees for
• Chest X-ray
• CBC
• Fecalysis
• Urinalysis
• Sputum Microscopy
• Preventive Services

To be provided by Accredited Health
Centers/Hospitals
To be provided by Accredited Hospitals
29
Benefit Payments
30
What we are doing

• 2nd round of increases in Inpatient ceilings in
  the 2nd semester of 2002
• Improvement in structure of some benefits e.g.
  hemodialysis, chemotherapy, emergency care
• Actuarial review of some planned benefit
  enhancements including FP / MCH, outpatient
  drugs, TB DOTS, vaccines

31
R e f
o r
m s
Phase 1 Hospitalization Program
Phase 2 RHU/HC Accreditation
P 888
Phase 2 Capitation Fund
PHILHEALTH CAPITATION FUND1
Phase 2 Benefit Delivery
Phase 2 Referral Scheme
32
NHIP Membership
PhilHealth covers 37.5 million Filipinos or 48
of population
33
Greater Medical Access The Indigent Program
640,422 HHs
The Indigent Program now covers 3.2 million
beneficiaries
34
Plan 500
207,340 HHs or 1.1 M beneficiaries
35
Ongoing Activities

• Reorganization
• ISP Implementation
• Online eligibility check
• Fraud control
• Online registration and premium payment
• Online claims processing
• Provider profiling
• Member profiling

36

• Issues and Concerns
• Access of services in rural areas
• Access of drugs and medicines
• Co-payment of Indigents
• Sustaining Indigent Program coverage
• Need for a responsive legislative agenda
• Need for a Responsive admin infrastructure
• Need for an attractive contribution and
  collection

37

• Lessons Learned
• Ownership of the Indigent Program by the Local
  Govt Executives and Indigent members
• Financial Access to health services that gives
  benefits
• Involvement of health professionals and medical
  associations to invest in the Program
• Special measures needed to include Informal
  sector in the NHIP
• Fraud Prevention

38

• Future Directions
• System Efficiency and Reliability
• Services Expansion and Quality
• Communication and Marketing Effectiveness
• Partnership Management
• Organization and staff productivity and
  management effectiveness

39
Thank you Very Much!
Thank You Very Much!