History
The Philippine Medical Care Program began in 1971 following the Philippine Medical Care Act of 1969. It mandated creation of the Philippine Medical Care Commission (PMCC). In 1990, bills were passed that led to significant improvement of public health care insurance. House Bill 14225 and Senate Bill 01738 became Republic Act 7875, known as "The National Health Insurance Act of 1995". Approved by PresidentMandate and Functions
PhilHealth has six major membership categories covering nearly the entire population. Those who count under the (1) "Formal" sector are workers employed by public and private companies and other institutions. (2) "Indigents" (also called "PhilHealth Ng Masa") are subsidized by national government through the National Household Targeting System for Poverty Reduction. (3) "Sponsored Members" are subsidized by their respective Local Governments (LGU). (4) "Lifetime" (non-paying) members are retirees and pensioners which have already paid premiums for 120 months of membership. (5) "Senior Citizen" (under RA 10645) allows all Filipino citizens 60 years old and above are eligible to have free PhilHealth coverage. (6) The "Informal Economy" is composed of Informal Sectors, Self-Earning Individuals, Organized Group, Filipino with Dual Citizenship, Natural-Born Citizen. Although treated separately, the Overseas Filipino Workers (OFW) program or Migrant Workers are a part of the Informal Economy. Migrant Workers are sub-categorized; whether if they are land-based or sea-based (for seafarers). Since 1996, the benefits package and delivery system have improved. PhilHealth now has an Outpatient and Diagnostic Package limited to indigent beneficiaries. This addition creates nearly comprehensive coverage for indigents. In 2011, 23 ''Case Rates'' was introduced and in 2013, ''All Case Rates'' was fully implemented. All other beneficiaries have access to nearly all comprehensive services, excluding some outpatient care. PhilHealth has an accreditation program for private hospitals. Some key reform indicators to date include: *Estimated coverage is 100% *Average period for payment of providers is estimated at 70 to 75 days. The law requires PhilHealth to reimburse providers and/or members within 60 days. A recent move , implemented a "simplified reimbursement scheme" wherein 95% of the amount of the claim is reimbursed after a rapid assessment of member and provider eligibility and the remaining 25% follows after detailed review of the claims. On average, 90 out of every 100 claims are paid, 3 to 4 are denied, and 6 to 7 are returned to health care providers for more information. 28% of claims were submitted by public providers and 72% by private providers.Funding and Revenues
Membership Categories
All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The national government payment is dependent on the availability of funds.Coverage
The benefits package is essentially the same for each membership category, PhilHealth deduction will depend upon the final diagnosis. The exception is for indigents and Overseas Filipino Workers (OFWs) who have additional outpatient primary care benefits (with the providers paid by capitation) however these benefits are available only through public providers.Benefits
PhilHealth and beneficiaries have access to a comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria andService delivery system
The service delivery system includes both public and private centers; on average, 61% of the network's providers are private and 39% are public. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health. The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB-DOTS and malaria, and private TB-DOTS clinics. Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth.Structure
The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector. PhilHealth has a governing board of 13 individuals, chaired by the Secretary of Health, with the President and CEO of PhilHealth as vice-chair. While the law, RA 7875, that created the National Health Insurance Program provides that the President and CEO has a fixed term of 6 years, with the passage Republic Act 10149 or the "GOCC Governance Act of 2011, Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year's premium and 3% of the income of the fund it manages towards operating expenses. Congress mandated that theProvider payment mechanism
Provider payment methods differ based on the illness or diagnosis. Case Rates are used for inpatient care, most day surgeries, and ambulatory procedures, TB-DOTS treatment, malaria care, deliveries, surgical contraception, and cataract surgeries, while primary care benefits providers are reimbursed based on a capitation system. No formal system sets deductibles or co-payments for beneficiaries, but health care providers are allowed to "balance bill", charging patients the balance between what PhilHealth pays and the total cost of care. This is atypical of most government health programs around the world and can lead to abuse by providers (e.g., overcharging) and thus limited access for the poorest. At the same time, balance billing allows providers additional cost recovery in the case that the reimbursement for services does not cover their cost.Quality
PhilHealth currently leverages internally developed quality standards. A new set of standards called the "PhilHealth Benchbook" was implemented starting January 1, 2010. The Benchbook was developed by PhilHealth with the assistance of various international health partners and several rounds of consultations with health providers. The previous and new quality standards are overseen by PhilHealth. The new quality standards focus on patient rights, organizational ethics, patient care, leadership and management, human resource management, information management, safe practice and environment and mechanisms of improving performance. As of 2011, hospital accreditation is valid for up to 3 years. PhilHealth accreditation staff physically check and verify compliance. PhilHealth has peer review committees mostly composed of health care providers who review specific cases. PhilHealth planned to implement quality-based purchasing but had not executed on this plan .Performance-based payment
PhilHealth has been developing incentives focused on payment to health care professionals. Doctors are usually independent practitioners who 'practice' in hospitals. Salaried government physicians are allowed to also engage in private practice. Efforts to implement case payments essentially focus on bundling the payment for the health facilities. Among PhilHealth's work in incentive-based payments is a scheme that has been piloted in 30 local government hospitals since 2002 but has not spread. The scheme is called the Quality Improvement Demonstration Study (QIDS). It utilizes clinical vignettes to measure quality of care. If a hospital meets a set quality of care index score, physician payments are increased. Clinical vignettes focus on the illnesses of children less than six years of age. Another incentive scheme is increased payment for health professionals practicing in areas where there is a lack of doctors.Claims processing
Claims processing and availability in accredited hospitals has been improved. Hospitals have installed the ICHP Portal System. It is established to provide a link between accredited institutional health care providers and Philhealth through online connections that shall ensure verification of eligibility information. Members don't need to fill out forms if they have updated premium contributions and PhilHealth records, but they may have to present their PhilHealth IDs. Members also don't need to submit their member data records. Claims are submitted to 17 regional claims processing centers. These centers initially review claims for eligibility. Review is input manually with data encoded into the claims processing information system. Once the claim is approved for payment, checks are prepared for the signature of regional heads. Electronic reimbursements are planned but has yet to be implemented.Monitoring and evaluation
PhilHealth conducts its own Monitoring and Evaluation, though the law mandates that University of the Philippines National Institutes of Health engages in monitoring of the scheme. Evaluations on the PhilHealth program are ongoing. The Department of Health (to which PhilHealth is an attached agency) monitors and analyses data, including number and value of claims, number of accredited providers, number and value of premiums paid, number of members, etc.Frauds and controversies
In 2013, fraudulent claims Juan Miguel of Regional 1 started fire with against the state-health insurer were estimated at 4 billion pesos. However, the state failed to prosecute erring doctors, private and public hospitals, and public officials. AFP Medical Center, St. Luke's Hospital, Philippine Orthopedic Hospital,PhilHealth to implement new contribution rate starting June
According to the Philippine Health Insurance Corporation (PhilHealth), the increase in contributions would be retroactive to January. This means that, in addition to the increased payments that will be collected from an employee's wage beginning next month, PhilHealth members will have to pay an extra 1% premium from January to May. The public health insurer previously declared that starting in June, premium rates will be collected at a rate of 4%. PhilHealth said in its Advisory No. 2022-0010 that members and employers who paid their contributions at 3% in the months before the premium rate hike starting next month "are advised to generate the corresponding Statement of Premium Account for the paid periods so they can settle the 1 percent differential payments/remittances until December 31, 2022." The rise in contributions is mandated by the Universal Health Care Act, which states that the premium rate will grow by 0.5 percent every year beginning in 2020 and continuing until it reaches 5%. The increase in premium contribution from 3% to 3.5 percent was scheduled to take effect in January 2021, but was postponed because to theReferences
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