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Moving Forward on Benefits

Board Sub Committee on Benefits
24 February 2016
PhilHealth Benefit Payments:
TSEKAP 2016

PhilHealth benefit payment is steadily increasing.
Claims reimbursement more than doubled in less than three (3) years

And yet, the top conditions paid by PhilHealth does not
match priority health conditions and,

Out-of-pocket spending remains to be high
PhilHealth Benefit Payments:
TSEKAP 2016
THE WORKPLAN:

Review the current case rates:
the “rates” of the case rates
claims processing system
conditions / requirements prior to payment

Work on New Benefits:
Launch benefits for priority conditions
with NBB for indigents and maximum co-pay for all other member types

All will be done in consultation with member / patient groups,
professional societies and provider groups
Working on the New Benefits:
TSEKAP 2016

Burden of Disease

Priority Index Cost Effectiveness

Equity Considerations
Putting the Rigor Back in Case Rates
TSEKAP 2016
SELECTIVE PRE PAYMENT MEDICAL AUDIT
IF and WHEN necessary, Regional RVP / Branch Managers will be given
1 the discretion to determine if pre-payment medical audit will be done for
selected providers or conditions or a combination depending on the source
of red flags in the region. Post payment monitoring will still need to be
strengthened.

REINSTATEMENT OF DOCUMENTARY REQUIREMENTS
Statement of Account (SOA) for all claims

2 Operative Record, if applicable
Claims Form 3 for all claims from Infirmaries & Level 1, > 1 day stays

If not submitted, the claim shall be returned to hospital for compliance
Pneumonia

2014 - P12.075 Billion
2015 - P 10.492 Billion

Policy statements released effective 15 September 2015. Among the conditions imposed were the
requirement of at least four (4) days confinement, three (3) days IV before shifting to oral antibiotics.

The policy statements were presented and approved by the Quality Assurance Committee (QAC) of
PhilHealth and eventually embodied in PhilHealth Board Resolution No. 1965.

Based on the latest stats, there has been a decrease in the number of cases paid by PhilHealth. For
HR CAP, 5,014 cases were paid in Oct 2015 and 3,691 in November 2015, down from 6,351 in
August before the effectivity of the circular. For MR CAP, 66,129 cases were paid in October 2015
and 52,288 in November 2015, down from 76,815 in August before the effectivity of the circular. Note
however that the November figures might not be complete yet because providers have 60 days or
until end of January to file the claim and hence, may still be in process.

The Philippine College of Chest Physicians (PCCP) in a letter dated Feb. 19, 2016 expressed
solidarity with PhilHealth as it seeks to have a meeting to discuss the current guidelines they are
updating or developing to “see how these can improve the coverage for these diseases”
UTI & AGE

UTI
2014 - P 1.810 Billion
2015 - P 1.960 Billion

Policy statements on the diagnosis and management of UTI released on 12 January 2016. The
prescribed length of stay is minimum of 96 hours (4 days). The policy statements were approved by
the Quality Assurance Committee (QAC) in its meeting on April 2015. In addition, the draft circular
was likewise sent to the societies prior to finalisation.

AGE
2014 - P 2.073 Billion
2015 - P 2.022 Biliion

Policy statements on the diagnosis and management released on 08 January 2016. the prescribed
length of stay is 72 hours (3 days). When it was being drafted, the policy statements were sent to
concerned societies for comments. Recent discussions indicate that the LOS may be reduced to 48
hours.
Cataract

2014 - P 2.081 Billion
2015 - P 2.424 Billion

The guidelines on the diagnosis and management of cataract effective 15 August 2015 prescribed the
maximum number of cataract pre-authorisations per surgeon at 10 a day and 50 a month. Other
conditions for quality care were emphasised in the circular like rules on the bilateral procedures, post
operative care and inclusion of IOL stickers in the claims forms.
Deliveries

Obstetric Care
2014 - P 3.183 Billion
2015 - P 3.792 Billion

This includes the following: (1) Maternity Care Package (MCP) - P6,500 if delivered in hospitals, P8,000 if
delivered in birthing homes / lying in clinics, (2) Normal Spontaneous Delivery (NSD) - P5,000 if delivered in
hospitals, P6,500 if delivered in birthing homes / lying in clinics, (3) Antenatal Care Package - P1,500, and
(4) Newborn Care Package (NCP) - P1,750

This figure would have to disaggregated to separate actual deliveries from the services intended for babies.
At least one region has raised the alarm of the increasing number of sick babies which may also drive
utilisation of these claims.

Caesarian Deliveries
2014 - P 2.179 Billion
2015 - P 2.314 Biliion

Among the proposals being discussed are:
•Pre-authorisation from within the hospital prior to CS, if emergency, would need concurrence of another
physician
•If without pre-auth, would be paid at NSD rate
•Separate accreditation for CS
Hemodialysis

2014 - P 4.714 Billion
2015 - P 6.209 Billion

Starting 28 July 2015, the amount per session was decreased from P4,000 to P2,600 but the
maximum number of sessions was increased from 45 days to 90 days. The 90 days is shared by the
member and the dependents.

Thailand experience can give us an insight into possible courses of action. First, they developed a
program to address rising incidence of hypertension and diabetes and secondly, they only admitted
patients into HD upon certification of non-compatibility with PD.

The current circular on HD provides the development of a Patient Registry. Once the registry is in
place, an option would be that new patients can only be admitted once such certification of non-
compatibility with PD can be secured. Supply constrains for solutions would be a challenge that needs
to be addressed.
Cardio Vascular

Stroke
2014 - P 2.630 Billion
2015 - P 2.788 Billion

Hypertensive
2014 - P 1.767 Billion
2015 - P 1.856 Billion
Potential Challenges
TSEKAP 2016
Expected longer turn around time (TAT) in claims
processing - Our commitment with the GCG (Government
1 Commission for GOCCs) is TAT of 30 days. Currently, we are at
27 days. We may have to re-calibrate our target but still should
be within the 60 days requirement of the law

Higher RTH - If claim forms that are not properly / completely filled
2 up or without the necessary supporting documents would be returned
to hospital for compliance, RTH rates would go up
Potential Challenges
TSEKAP 2016

COA issue - If the actual amount stated in the SOA is less than the
case rates, the COA will question why we are paying higher than the
3 actual amount. But we will position the amount stated in the SOA not
as basis for payment but for purposes of calibrating / adjusting the
case rates

Recalibration of existing resources - Since implementation of All
Case Rates and medical audit became post processing requirement,
4 some doctors were assigned to other tasks or the positions were not
filled up when vacated.

Aside from HR complement, IT resources needs to be recalibrated
Timetable
TSEKAP 2016
Key Activities Target Dates

Presentation to the Board Sub Committee on
Feb 24
Benefits / full Board (if warranted)

Engaging the Providers (professional groups
March 4
and hospital associations)

Admissions starting two
Effectivity of the Policy
weeks after publication