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CHAPTER IV

WHOLISTIC-PROBLEM SOLVING ANALYSIS

PhilHealth is mandated to provide social health insurance to all Filipinos. Part of

its function, is to reimburse accredited health care providers with the health services they

provide to the PhilHealth members. The process of claiming reimbursement involves

submitting pertinent documents to PhilHealth. Under Implementing Rules and

Regulations of PhilHealth, the HCIs are provided with 60 days after the discharge of the

patient to submit complete and accurate documents to PhilHealth in order to for payment

to made to the HCIs. This study focuses on the section – Benefit Administration Section

which is tasked to receive documents, evaluate the same and forward the documents to

Finance Management Section for payment to HCIs.

Problems exist in the Benefit Administration Section and may be caused by man,

material, machine, money, method, measurement, and management of time. In this study,

the Wholistic Problem-Solving Analysis is used to ascertain the most persistent problems

in BAS. This study involves identifying and clarifying the problems. It also includes

phases in prioritizing, selecting, and analyzing problems. The last part, is deciding the

best solutions possible.

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A. Generating and Clarifying the Problem

1. Delayed Processing of claims documents

2. Absenteeism

3. Unskilled staff/encoder

4. Demotivated Staff

5. Involvement in marketing activities

6. Slow pace of procurement process

7. Slow System connectivity

8. Outmoded computers

The problems identified were further ranked according to the most pressing that currently

troubles BAS which enabled the researchers to arrive at a shortlist. The following

problems were:

1. Delayed Processing of Claims Documents

The Benefit Administration Section has 5 encoders. Each encoder has a quota

of 160 claims documents per day. BAS receives an average of 2,500 claims

documents every day. Taking into consideration that all 5 encoders reached

their quota, their output would only be 800 documents. There will still be a

backlog of 1,700 documents per day. In order to fast track payment BAS has

to finish encoding in order to move to the next stage of the process which in

the Finance Management Section.

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2. Slow pace of procurement process

The encoders’ output is the Validation Report. It has data on how much would

be the reimbursement to the health care provider alongside with other

information. It should be printed and attached to the claim document. There

are times that the process cannot move to the next stage because the printing

of the document is unsuccessful. There are times that ink of the printer is not

sufficient, thus, producing unreadable Validation Report. There are also

instances that there are no available ink cartridges. These occasions place the

process in a stand still.

3. Involvement in marketing activities

There are times that conferences, fora and marketing activities, are taken to a

bigger scale like the nationwide and simultaneous PhilHealth Run, Visayas

Area III Summit (which involved Region 6,7, and 8) and other conferences

and fora. Such marketing endeavors require a lot of personnel from

preparation to implementation. Most of the time, the personnel under BAS are

enlisted to be members of the different committees. These committees meet

frequently during the preparation until implementation. Such activities disrupt

the output of the encoders. In addition, the encoders are occasionally tapped to

be speakers and/or facilitators in the conduct of IEC and orientations. These

require time to organize like preparation of procurement documents for the

venue and food, preparation of presentation materials, preparation of

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invitations among many other related necessities. On cases such as these a lot

of “encoding time” is lost to these activities.

4. Demotivated staff

Absenteeism and tardiness are manifestations of unmotivated staff. A good

number of encoders manifest this kind of attitude. Both behaviors result to a

decrease in the number of working hours. It would be very difficult to catch

up with lost time. Its impact to the encoding output is negative.

5. Slow system connectivity

The module which is used in the encoding is “on-line”. It is dependent to the

connectivity of the system. In many cases encoders complain that the system

always lags, hang, or pause. These occasions directly lower the encoders’

output.

B. Prioritizing and Selecting a Problem

After identifying the problems that affect BAS, the researchers’ respondents were

requested to rank them to the degree of recurrence. The five (5) problems

identified with more pressing significance were ranked by the respondents from

1-5, where 1 represents the highest degree of recurrence and 5 with the least

degree of recurrence. Table 1 presents the frequency of the identified problems

experienced in BAS.
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Table 1. Frequency of the Identified Problems

Problems Frequency (F) Percentage Cumulative

1. Delayed 4 40% 40
Processing of
Claims
Documents
2. Slow pace of the 3 30% 70
procurement
process
3. Involvement in 1 10% 80
marketing
activities
4. Slow system 1 10% 90
connectivity
5. Unmotivated 1 10% 100
Staff
TOTAL 10 100%

As presented in Table 1, four (4) respondents (40%) agreed that Delayed

Processing of Claims Documents is the most recurring problem in BAS. Three (3)

respondents (30%) viewed that the Slow Pace of Procurement Process as the

second most recurring problem. Lastly, 3 respondents have different views stating

that (apart from each other) Involvement in Marketing Activities, Slow System

Connectivity, and Unmotivated Staff are the most recurring problems.

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Table 2. Pareto Chart

10 100%

9 90%

8 80%

7 70%

6 60%

5 50%
Frequency
4 40%
Cumulative (%)
3 30%

2 20%

1 10%

0 0%
Delayed Slow pace of Involvement slow system Unmotivated
Processing of the in marketing connectivity staff
Claims procurement activities
Documents process

C. Analyzing the Problem

Analyzing the problem consists of Problem Statement, Desired State/Goal,

Generating Possible Causes of the Problem, Categorizing Possible Causes - using the

Fishbone Diagram, and Identifying the Root Cause.

c.1. Problem Statement

There is a delay of processing of claims documents in the Benefit Administration

Section in PhilHealth Regional Office VIII.

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c.2. Desired State/Goal

The Benefit Administration Section of PhilHealth Regional Office VIII should be

able to increase encoding output by 100% to cope with the increasing number of

claims documents filed for reimbursement.

c.3. Generating Possible Causes of the Problem

The following are the possible causes generated in the focused group discussion

between the researchers and the staff under BAS-PRO VIII, to wit:

1. No budget of additional staff

2. Increasing number of claims documents received

3. No formal training for BAS personnel

4. Transfer of personnel from BAS to other sections or divisions

5. Low number of skilled encoders

After a series of discussion between the respondents and the researchers, both

agree that the most probable causes are the following:

c.4. Categorizing Possible Causes

The Fishbone Diagram or the Ishikawa Diagram, Figure 1. , is one of the tools in

identifying the root cause of the problem. It provides a schematic diagram that shows

the relationship between the problem (effect) and the causes.

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Figure 4. Root Cause Analysis

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Table 3. Supplemental Analysis of Root Cause

POLICIES/IMPLEMENTATION

 Incomplete dissemination of procedures

 Lacking work instructions

ATTITUDE

 Force of habit
 Tolerance
 Abuse of authority
 Uncaring attitude of staff
 Passive attitude towards task at hand

ADMINISTRATIVE

 Absence of disciplinary procedures

 Negligence of accountable staff
 Subjective enforcement of policies
 Lack of necessary equipment
 Poor planning, organizing and control
 Ineffective supervisors

There are five (5) categories that comprise the diagram.

1. Manpower

 Less interest in encoding tasks

o Encoding is perceived as a boring task

 Failure to reach quota

o Absenteeism and Tardiness

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o Lack of motivation

o Senior staff are perceived as antagonistic

2. Material

 No available ink

o Untimely delivery of supplies

o Late procurement

o Late submission of purchase request

3. Machine

 Slow connectivity

o Internet provider problem

4. Measurement

 Quota is too difficult too difficult to achieve

o The number of documents is too many

o There is a need to increase the quota in order to

reimburse to the HCIs immediately

5. Method

 Encoding is confusing and tedious

o Encoding process is difficult to understand

o Lack or no formal training

D. Deciding the Best Solution

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The research presents a balanced way of coming up with a solution by stating its

Purpose, Setting of Criteria for Evaluating Alternative Courses of Action and,

Determining the Best Alternative using a Criteria in determining the best solution.

d.1. Purpose

The purpose of this re-entry plan is to be able to identify a solution to the

problem in the Benefit Administration Section of PRO VIII involving the

shortage of manpower complement specifically, encoders.

d.2 Identify the Possible Solutions

The researchers have identified some possible solutions to the problem

affecting BAS. The following are the suggested solutions:

1. To hire additional personnel and assign them in Benefit

Administration Section

2. To re-assign personnel from other divisions/sections to BAS

3. To provide formal training to encoders and potential encoders

4. To upgrade the module for encoding

5. To upgrade system connectivity

d.3. Determining the best alternative courses of action

Considering the effectiveness and efficiency in solving the problem, the

researcher narrowed the list into three (3) possible solutions.

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Alternative A: To hire additional personnel and assign them in Benefit

Administration Section.

One of the possible solutions to the problem is to hire additional staff for

BAS. There are a number of positions in the BAS which are currently vacant. The

additional workforce that will be hired will reinforce the number of encoders.

Thus, the additional encoders will contribute in the output and eventually decrease

the encoding backlog.

Alternative B: To reassign personnel from other Divisions/Sections.

It is a possible option that personnel from other Divisions/Sections can be

re-assigned in BAS. However, it would result to the same problems for the

Divisions/Sections from where the personnel are originally assigned. Proper

consultations with concerned supervisors and adjustments should be made in

order not to compromise their work output. The key indicators can be adjusted in

order not to overwhelm the remaining workforce. Deliverables can also be

allocated to other sections in order to distribute the work load.

Alternative C: To provide formal training to encoders and potential encoders

Encoding is a skill that can be taught and developed. There is a protocol in

encoding claims documents that if followed will ease the encoders from

confusion. The errors will be prevented and the tedious task of re-encoding will

be prevented. There are techniques and short-cuts that are very essential for an
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efficient and effective encoding. Unfortunately, these techniques are known to

some who have attended formal training in ICT. Some encoders are self-taught

and have developed their skill through experience. Sometimes some of the

knowledge acquired through the years are incorrect. Formal training should be

mandatory to all encoders. The trainees that would not pass the training standard

should not be allowed to be a BAS encoder.

Table 4. Defined Criteria with their Corresponding Weights

Criteria Defined as Weight

Ease of Implementation How easy would it be to implement the 12%

solution?

Probability of Success How likely is it that the solution itself 30%

could be successfully implemented?

Effectiveness of How effective would the solution be in 50%

Solution addressing the root causes and solving

the problem?

Relatively Low How much resistance might there be to 8%

Resistance implement this solution?

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The three alternative courses of action were evaluated using the Criteria Rating

for determining the best solution as shown in Table 4. Each alternative is given a score

that would establish which is best among them alternative solutions.

Table 5. Application of Criteria to Identified Alternative Solution

Criteria Weight A B C
(%) To hire To conduct staff To acquire
additional development/ state of the art
staff for BAS training computer
facilities
Ease of 12 7 5 6
Implementation (0.84) (0.6) (0.12)
(How easy
would it be to
implement the
solution?)
Probability of 30 8 7 6
Success (2.4) (2.1) (0.3)
(How likely is it
that the solution
could be
successfully
implemented?)
Effectiveness of 50 7 6 5
Solution (3.5) (3.0) (2.5)
(How effective
would the
solution be in
addressing the
root causes and
solve the
problem?)
Relatively low 8 9 4 7
resistance (0.72) (0.32) (0.56)
(How much
resistance these
might be in
implementing
this solution?)
Total Points 100% 7.46 6.02 3.48
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Table 6. Determining the Best Solution Using Impact and Probability as Criteria
ALTERNATIVE POSSIBLE ADVERSE CRITERIA INTER-
SOLUTIONS CONSEQUENCE IMPACT PROBABILITY PRETATION
(High, (High,
Medium, Medium, Low)
Low)

1. Hire  Budget
additional constraints
staff  Insensitive
recruits Low Low 1
 Implementatio
n is not
immediate

2. Training  Inefficient
despite
training
 High training
costs High Medium 3
 Resistance to
new and
advance
technology

3. Reassignm  Resistance to
ent of learning to
Personnel processes
 Feeling of Medium Low 2
Contempt
against
management
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The three (3) alternative solutions were rated by the respondents from 1 to 10,

where 10 was the highest and 1 was the lowest score. Table 4 shows the weight of

each criterion. The score of each alternative solution was multiplied by the weight

assigned to each criterion. The products of which were summed to get the total points.

The alternative solution that garnered the highest point is the best solution.

Alternative A, “To hire additional staff for BAS” is the best solution with 7.46

points. It is more feasible and has the highest possibility of success in

implementation.

E. Action Plan

The action plan is a tool and a guide in accomplishing a solution to a problem.

The action plan includes a list of activities to be carried out at certain stages of the

implementation.

GOAL: To pay the health care institutions immediately after providing health care

services to PhilHealth members

OBJECTIVE: To decrease the backlog in encoding by 50% after 6 months from

hiring of new encoders and reach 0% backlog after 1 year from

hiring of new encoders