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THE NO BALANCE BILLING (NBB) POLICY OF

PHILHEALTH IN WESTERN VISAYAS:


COMPLIANCE, DIFFICULTIES AND INITIATIVES
OF HEALTH CARE INSTITUTIONS

TOCHE VIC B. DOCE


Researcher
Capiz State University – Pontevedra
College of Business Administration
Situationer 1
Renato, a 65 year-old farmer with a very low
monthly income, sought consult from a government
hospital because of blurred vision. He was
diagnosed to have senile mature cataract, left eye
and was advised to undergo cataract surgery. He
was also advised to be admitted prior the surgery
date for clearance of medical problems including
hypertension and pneumonia.
Renato thought he needed miracle for him to get
treated without spending any amount in the
hospital… “Pigado guid, wala inugpabulong.”
Situationer 2
Celia, a 31 year-old single mother, brought
her 3 year-old child (Sam) in the emergency room
of a government hospital because of labored and
difficulty of breathing, fever and malaise. The
pediatrician admitted the child with a working
diagnosis of PCAP-HR.
With only 300 pesos in her wallet and a 4Ps ID
in her name, how can she (Celia) ensure the
recovery of her child (Sam) from such condition?
Question
• Is it possible that Renato will be admitted for
his medical condition and operated for his
cataract without thinking of his hospital bills?

• Is it possible for Celia to have her child (Sam)


be admitted and treated for a serious illness
with only 300 pesos and a 4Ps ID?
Answer
Introduction
PhilHealth
• Govt owned and controlled corporation
• Created by Republic Act 7875 (1995)
• National Health Insurance Program (NHIP)
• Amended by RA 9241 and RA 10606
• Access to health care is a basic right of citizens
– “Universal coverage” or “Kalusugan Pangkalahatan”
Introduction
• In partnership with Local Government Units (LGUs),
PhilHealth has enrolled millions of families who
otherwise have no access to health services.

• Since then, this program has been at the heart of


PhilHealth’s program and now forms the bulk of
membership.

• To date, all families in the DSWD’s National Household


Targeting System for Poverty Reduction (NHTS-PR) are
covered by PhilHealth. This includes 4Ps members.
Introduction
• In 2010, the newly-elected government under President
Benigno C. Aquino launched a major reform effort aimed at
achieving ‘universal health coverage’

• In 2011, PhilHealth has implemented case-based payment


scheme which offers a more predictable and equitable
benefit payment based on patients' medical condition.

• Introduction of the No Balance Billing (NBB) Policy, which


provides that no other fees or expenses shall be charged or
be paid for by the indigent and sponsored patients above
and beyond the packaged rates (PhilHealth Circular No. 11,
s. 2011).
Rationale
What is… What should be…

In 2013, there is a Universal health coverage


decline in benefit for all Filipinos.
availment.

Not all members are Increase in enrollment


aware of their and coverage of poor
insurance coverage. families.
Rationale
What is… What should be…

During its first year, Financial risk protection


compliance is only 7% for the poor should be
(2013, PhilHealth Annual ensured.
Report)

In 2014, the There should be high


compliance increased compliance to NBB since it
to 40%. Still a low is mandated through a
figure. circular and a statute.
Rationale
What is… What should be…

Resource constraints have


proved to challenge the
effective implementation of the
NBB policy NBB policy should be
implemented easily and
The strong political will of both smoothly as guided by
national and local government
to do their share in resource law.
management and policy
enforcement to assure that
every poor Filipino is truly
protected against financial risk
is missing.
Discrepancy
• This policy appears to be a very beneficial
policy especially those belonging to the
marginalized segment of the society. But why
is it that compliance seems to be elusive?

• Casual observations from people in the field


also reported deteriorating trend of
compliance in the first semester of the current
year.
Statement of the Problem (Quan)
1. What profile can be drawn from the samples in terms of:
– Level of HCI Accreditation
– Membership Category
– Nature of Case Rate
2. What is the extent of compliance of HCIs in Western Visayas
towards NBB policy?
– In a six-month period (November 2014-April 2015)
– Taken as a whole
3. Is there a significant difference in the extent of compliance
when grouped according to the 3 profile variables?
4. What are the components of NBB services that are not
complied by HCIs?
Statement of the Problem (Qual)
5. What are the difficulties encountered by HCIs
toward NBB policy?
6. What are the mechanisms initiated by HCIs to
ensure NBB policy compliance?
Methodology
Design, Sampling, Locale, Tool and Informants
- Mixed methods research design, particularly the
explanatory sequential design.
- For the quantitative part, 1,919 member samples were
taken from the PhilHealth Patient Feedback Form Survey
of the PhilHealth Regional Office VI for the period of
November 2014 to April 2015 using Simple Random
Sampling.
- Phase two (qualitative part) of the study was composed
of joint/group interviews of PCARES deployed in
accredited government healthcare institutions in Aklan,
Antique, Capiz, Guimaras, Iloilo, and Negros Occidental.
Purposive sampling was employed.
PCARES Team - Informants
Methodology
Data Gathering and Data Analysis
- Appropriate permits were secured from PRO VI, Iloilo.
- Limitations on the use of data was observed in
accordance with PhilHealth’s confidentiality rule.
- Written consent was secured from each participant in
accordance with the ethics of research.
- Quantitative data were processed through SPSS v. 20
using appropriate statistical tools.
- Qualitative data were transcribed, summarized and
categorized. Topics and subtopics were developed.
Exit Survey
FINDINGS
Finding No. 1
The distribution of respondents according to hospital level, membership category and
nature of case rate.

PROFILE VARIABLES FREQUENCY (f) PERCENTAGE (%)


Hospital Level:
Primary Care Facility (PCF) 200 10.4
Level 1 968 50.5
Level 2 212 11.0
Level 3 539 28.1
TOTAL 1919 100.0
Membership Category:
Indigent 1521 79.3
Sponsored 398 20.7
TOTAL 1919 100.0
Case Rate:
Medical 1342 69.9
Surgical 577 30.1
TOTAL 1919 100.0
Finding No. 2
80
73.5
69.2
70 66.9
62.5 61.9
60 56.2

50
40 High
40
33.7 Moderate
31.8
30 26.9 Low
25.4 24.5

20

10 5.4 6.3 6.3


3.8 3.8
2
0
Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

Figure 2. The extent of compliance on NBB policy of HCIs in Western Visayas from
November 2014 to April 2015.
Finding No. 2
Overall Extent of Compliance

Low Compliance,
4.6 High Compliance,
30.4

Moderate
Compliance, 65

High Compliance Moderate Compliance Low Compliance

Figure 3. The overall extent of compliance of HCIs on NBB policy in Western Visayas
from November 2014 to April 2015.
Finding No. 3
The mean differences in extent of compliance to NBB policy when grouped
according to profile variables.

PROFILE VARIABLES MEAN TYPE OF TEST COEFFICIENT SIG.


Level of HCI Kruskal-Wallis H 128.456** 0.000
PCF 2.45
Level 1 2.34
Level 2 1.95
Level 3 2.15
Membership Category Mann-Whitney U 297270ns 0.510
Indigent 2.25
Sponsored 2.28
Nature of Case Rate Mann-Whitney U 346741** 0.000
Medical 2.30
Surgical 2.17
ns – not significant ** - highly significant
Finding No. 3
The post-hoc analysis on mean differences between extent of compliance to NBB policy and
level of HCI accreditation.

LEVEL OF HCI WEIGHTED MEAN** VERBAL INTERPRETATION


PCF 2.45a High Compliance
Level 1 2.34b High Compliance
Level 2 1.95d Moderate Compliance
Level 3 2.15c Moderate Compliance
** - highly significant
abcd
- means with the same letter superscript were not significantly different
Finding No. 4
Medicines

Complied,
34.3

Not
Complied,
65.7

Figure 6. The compliance on medicines.


Finding No. 4
Supplies Laboratory/Diagnostics

Not
Complied
Not , 14.1
Complied
, 27.7

Complied
Complied
, 72.3
, 85.9

Figure 7. The compliance on supplies. Figure 8. The compliance on laboratory


and diagnostics
Finding No. 4
Blood/Blood Products Professional Fee
Not
Not
Complied
Complied
, 1.2
, 3.1

Complied
Complied , 98.8
, 96.9

Figure 9. The compliance on blood/ Figure 10. The compliance on professional fee
blood products
Finding No. 5
No balance billing policy implementation suffered from
operational, structural and external difficulties.
a. Operational difficulties include availability and
adequacy of drugs and medicines, absence of
essential diagnostic procedures, and absence of blood
banks.
b. Structural difficulties include issues on funding and
prioritization, lag in procurement process and non-
adherence to CPGs.
c. External difficulties include issues on adequacy of
case rates and enterprising.
Finding No. 6
Healthcare institutions employ certain mechanisms
to ensure, or at least improve NBB policy implementation.
These include:

a. creation of MOA
b. consignment system
c. LGU support
d. internal hospital control

However, these mechanisms are proven to be with


limitations.
CONCLUSIONS
CONCLUSIONS
1. The NBB-entitled members were indigents
seeking medical management in a Level 1 –
accredited government health care
institution.
2. The healthcare institutions in Western
Visayas are moderately complying on the
NBB policy of PhilHealth. High compliance is
only achieved in every 3 out of 10 admitted
members.
CONCLUSIONS
3. Primary Care Facilities (PCFs) have significantly
higher compliance when compared to other
levels of healthcare institutions.

The level of HCI accreditation affects extent of


compliance to NBB policy. The lower the level of
HCI, the higher is its compliance. HCIs can also
comply better with sponsored members requiring
medical management than those requiring
surgical interventions.
CONCLUSIONS
4. At least 2 in every 3 NBB-entitled members
are spending out-of-pocket expenses for
medicines and 1 in every 3 NBB-entitled
members are spending OOPs for medical
supplies.
CONCLUSIONS
5. Full compliance to NBB policy in Western
Visayas is hindered by operational, structural
and external difficulties. All of which remain
to be a challenge for healthcare institutions.
6. As part of their performance commitment,
healthcare institutions are adopting
mechanism to improve compliance but most
were proven to be short-term and remedial
in nature.
RECOMMENDATIONS
Recommendations
1. The national and local government units taking charge
of retained and devolved HCIs should give more
priority to the health sector by increasing funding and
allocation to realize the goals of NBB policy to provide
financial risk protection to the poor.

2. Healthcare institutions should formulate an NBB team


composed of hospitals staff from different
departments to lead an internal control committee. A
multi-sectoral and collaborative effort within the
facility can be of great help to ensure NBB policy is
well-implemented.
Recommendations
3. PhilHealth should develop stricter sanction mechanism to
discipline erring healthcare institutions which may include
monetary penalties, claims adjustments and revocation of
accreditation, subject to approval of the appropriate authorities.
In same way, the corporation should also grant incentives to
performing healthcare institutions to motivate them to sustain
high compliance.
Recommendations
4. PhilHealth should initiate inter-agency dialogue or
coordination with concerned government agencies and
corporate stakeholder to review the criteria of NBB
compliance based on the perceived difficulties encountered
by HCIs.

5. No balance billing policy should be a prime thrust of


PhilHealth as it produces satisfaction and appreciation from
the masses at the point of benefit availment. Similar projects
like PhilHealth CARES can be instituted to monitor compliance
of HCIs and empower indigent and sponsored members of
their right to financial risk protection during medical
emergencies.
“Laws are beautifully made. However,
it is only in the implementation phase
that its gray areas are usually noticed.”

- TVBD
THANK YOU AND
AN NBB DAY TO
ALL OF YOU!