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PhilHealth: Perfecting the system

to produce better outcomes

Plugging the Holes for a Wider Benefit

Anthony Leachon, MD, FPCP, FACP
Independent Director
Representative of the Monetary Board

1. PhilHealth mandate, mission and vision
2. History and Milestones
3. Types of membership
4. Membership coverage
5. Benefits and benefit pay-out
6. Successes and landmarks
7. Challenges and opportunities
8. Call to action
 Single Fund/Single Payor

 Draws inspiration from
concept of ‘bayanihan’

 Coverage of about 92%*
percent of population


 Offshoot of Medicare
*Artwork by Filipino National Artist
* As of Nov. 2015
Carlos "Botong" Francisco
Vision and Mission
History and Major Milestones
Bawat Pilipino, MIYEMBRO

Formal Informal Sponsored Indigent Lifetime Senior
Economy Economy Members Members Members Citizen
Covered beneficiaries by Sector

Source: PhilHealth Stats and Charts, 2015
Benefit payment

2013 – less than P1.1B a week
2014 – less than P1.5B a week
2015 – less than P1.9B a week

Source: PhilHealth Stats and Charts
PhilHealth Successes, Landmarks
92% Much gains have happened…
Z benefits &
NBB in public hospitals Passage of
for indigents RH Law
Enabling environment
> Php 200B combined for access & Strengthened food
resources compliance and drug
Health facilities
upgrading Increasing
Sin taxes for LGU success
health stories

Expanded free Health worker
medicines and deployment
vaccines programs

Slide courtesy of Dr. Beverly Ho, DOH, 2016
But many areas still require more
work for it to be felt by all
Focus on curative care

56% 3X Disparity between wealthiest
and poorest quintile
OOP at all-time
high NATIONAL IMR 23/1,000

Quality and safety are
not assured
~60% NBB compliance

Poor referral system
Not that responsive

Slide courtesy of Dr. Beverly Ho, DOH, 2016
The top conditions paid by PhilHealth do not match priority
health conditions and are focused on costly interventions

TOP 10 Medical Cases TOP 10 Procedures
1.Pneumonia 1.Hemodialysis
2.AGE 2.Newborn care package
3.UTI 3.Routine obstetric care including antepartum,
4.Dengue with warning signs vaginal delivery and/or post partum NSD
5.Bronchial asthma with exacerbation (hospitals)
6.Dengue without warning signs 4.Routine obstetric care including perinatal
7.Hypertension, stage II delivery and newborn services MCP (non-
8.Essential hypertension hospital facilities)
9.Bacterial sepsis of newborn 5.Cataract removal
10.Other acute gastritis 6.CS, primary
7.CS delivery
8.Radiation treatment delivery
9.Vaginal delivery only
Source: PhilHealth Stats
and Charts, 2015
TOP 10 Causes of Mortality TOP 10 Causes of Morbidity
1.Diseases of the heart 1.Acute respiratory infection
2.Diseases of the vascular system 2.Acute lower respiratory tract
3.Malignant neoplasms infection and pneumonia
4.Pneumonia 3.Bronchitis/bronchiolitis
5.Accidents 4.Hypertension
6.TB, all forms 5.Acute watery diarrhea
7.Chronic lung disease 6.Influenza
8.DM 7.UTI
9.Nephritis/ nephrotic syndrome/8.TB
nephrosis 9.Injuries
10.Perinatal disease 10.Diseases of the heart

Source: DOH, 2010
And from the patient’s perspective, UHC is unclear

Aling mga Mayor
serbisyo ang Sa private nalang kasi
libre? malinis at kumpleto
ang gamit...di bale na Ewan! DOH
Saan ako Sakit sa
pupunta mamumulubi.. Asahan mo
tiyan, e di sa
kung may na ang BILL
sakit? SHOCK!
PCSO Uutang
Hindi nalang
Magkano malinaw.
kaya aabutin .
ng bill?

Saan ako
ng tulong?

Slide courtesy of Dr. Beverly Ho, DOH, 2016
A glimpse on the vision of PhilHealth benefits

Slide courtesy of PhilHealth & Epimetrics, 2016
Call to Action
• Improve reimbursement policies based on evidence –
CPGs and standards
• Put rigor in the process
• While NBB for indigents is strictly imposed, DOH
and LGUs should improve supply side
• Introduce maximum copay for other members
• Improve primary care to prevent inpatient care and
costly interventions
• Develop systematic and evidence-based Benefit Plan
Perfecting the system through policy
• Pre-authorization for cataract and Z benefits
• Installed controls in reimbursement based on CPGs
(e.g. Length of stay for pneumonia, UTI and AGE)
• Strengthen HCP Performance Assessment System to
ensure quality of care, financial risk protection, patient
satisfaction and fraud prevention
• Put rigor in the process through reinstatement of SOA
• Work towards pre-payment medical audit
• Use of data analytics to understand provider and
population behavior
Priority setting initiative
Review of Focus Group Round Table Discussion
Literature Discussions with Experts

Public Health
Evidence Based
Health Policy
Thailand Australia UK Chile Health
Slide courtesy of PhilHealth & Epimetrics, 2016
Slide courtesy of PhilHealth & Epimetrics, 2016
Proposed Priority Setting Principles

Inclusiveness and Transparency
Ethical Soundness Preferential Regard Scientific and
Rigor Accountability
to the Underserved

Availability of
Efficiency Enforceability Remedies and Due

Slide courtesy of PhilHealth & Epimetrics, 2016
Proposed Priority Setting Steps

1Nomination of
Shortlisting of
3 Generation of
Interventions Interventions Evidence

4 Appraisal of
Approval for
6 Approval for
Evidence Coverage Implementation

Slide courtesy of PhilHealth & Epimetrics, 2016
Proposed Criteria

Magnitude and Household
Severity with Equity Effectiveness Financial
Component Impact

Cost Implications
Cost Effectiveness to the Health

Slide courtesy of PhilHealth & Epimetrics, 2016
“If we keep doing what we have been doing,
we’ll keep getting what we’ve always

-Dr. Paul Batalden, Institute for Healthcare

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