Successes and Failures in expanding and deepening coverage of health protection - the Philippine experience
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1 Successes and Failures in expanding and deepening coverage of health protection - the Philippine experience Eduardo P. Banzon, MD, MSc Senior Health Specialist World Bank
2 Health Protection CHARITY BEDS IN GOVERNMENT HOSPITALS HOSPITALS FREE PUBLIC HEALTH/ PREVENTIVE HEALTH SERVICES and PRIMARY MEDICAL CARE SERVICES in GOVERNMENT HEALTH FACILITIES HEALTH UNITS/ CENTERS/ SOCIAL HEALTH INSURANCE HOSPITAL SERVICES in PUBLIC and PRIVATE HOSPITALS SELECT OUTPATIENT SERVICES OPD DEPARMTENTS of PUBLIC HOSPITALS
3 CHARITY HOSPITAL BEDS National Government Budgets DoH Hospitals University Hospitals AFP, PNP & Veterans Hospitals 90% 90% charity beds by a 1947 Law Local Government (LGU) Budgets LGU Hospitals 90% Private Hospitals Household Out of Pocket Payments 10% 10% charity beds by DoH administrative order
4 CHARITY HOSPITAL BEDS Government budgets not enough to provide all necessary medicines/ diagnostics Budget for DoH hospitals have decreased in real terms in the last five years IN RESPONSE, a patient classification scheme (Class A to D) Class D patients 100% subsidy Class C1 C3 A increasing share in underwriting the cost of hospital care with Class A expected to pay full costs HOWEVER, Class D patients are still being made to pay from out-of-pocket unavailable medicines and diagnostics 10% CHARITY BEDS in PRIVATE HOSPITALS No clear funding source Poor monitoring and NO DATA on compliance HOSPITALS
5 PHILHEALTH BEDS/ WARDS National Government Budgets DoH Hospitals University Hospitals AFP, PNP & Veterans Hospitals PHILHEALTH BEDS or WARD Local Government Budgets LGU Hospitals PhilHealth (SHI) Coverage Private Hospitals PRIVATE ROOMS or BEDS Household Out of Pocket Payments PRIVATE HEALTH INSURANCE
6 Source: PhilHealth internal databases
7 FREE PRIMARY CARE SERVICES Public health and preventive health Devolved to local governments Dependent on local government budget financing BUT, national government still finances vaccines and drugs for key public health programs such as tuberculosis and schistosomiasis Primary medical care services Health center or OPD of public hospitals ALSO dependent on available budgets NO national policy/program committing to ensure ACCESS to essential outpatient medicines
8 PhilHealth finances professional health care with diagnostics for indigents Preventive and Promotive Services Outpatient Consultation and Diagnostic Benefit Package thru Accredited Rural Health Units, Health Centers and Authorized Hospitals Primary consults Laboratory fees for: Chest X-ray CBC Fecalysis Urinalysis Sputum Microscopy Preventive Services Visual acetic acid screening Regular BP measurements Digital rectal exam Body measurements Clinical breast exam Counseling for smoking cessation Lifestyle modification counseling
9 MEDICARE (since 1971) (Private workers, Self-employed & retirees) (Govt. workers & retirees) SPONSORED PROGRAM (Indigent Families) (Overseas Workers)
10 NG- national govt. LG- local govt. Means testing Year 1st 2nd 3rd 4th 5th 6th 7th 8th 9th onwards City Municipality (1 st 3 rd class) NG Share P600 P600 P600 P600 P600 P600 P600 P600 P600 LGU Share NG Share Municipality (4 th 6 th class) LGU Share % Amount % Amount P600 90% P1,080 10% P120 P600 90% P1,080 10% P120 P600 85% P1,020 15% P180 P600 80% P960 20% P240 P600 75% P900 25% P300 P600 70% P840 30% P360 P600 65% P780 35% P420 P600 60% P720 40% P480 P600 55% P660 45% P540
11 Legal Spouse/s Primary Member Children below 21 yrs old Parents 60 yrs old & above
12
13 160% 140% 120% 9,118 (2007 Enrollment) 8,551 (2010 Target) 172,060 (2007 Enrollment) 116,982 (2010 Target) 147% 145% 88,932 (2007 Enrollment) 87,156 (2010 Target) 134% 63,929 (2007 Enrollment) 43,997 (2010 Target) 124,517 (2007 Enrollment) 92,930 (2010 Target) 107% 10 2 % 100% 80% 69% 60% 43% 40% 20% 0% 24% 10 % 13 % 0% 26% 20% 15 % 1% 9% 3% 23% 12 % 26% 36% 35% 35% 1% 0% 1% 6% 5% 8% PRO IX PRO X PRO XI PRO XII PRO-CARAGA PRO ARMM
14 Unified Inpatient Packages Other Packages Maternity Care Package Day Surgery Benefit Outpatient TB Package Dialysis, Chemotherapy & Radiation Therapy Outpatient benefits for the poor
15 Source: PhilHealth 90% claims made by hospital to PhilHealth. predominantly fee-forservice
16 Illustrative PhilHealth does not negotiate prices with hospitals for its members
17 Illustrative
18 Illustrative
19 Source: PhilHealth internal databases
20 SUPPORT VALUE in PRIVATE HOSPITALS is quite POOR Source: PhilHealth internal databases
21 Source: Department of Health, GoP PhilHealth created
22 Source: World Health Report 2006
23 Source: Philippine National Health Accounts
24 Source: Philippine National Health Accounts
25 Conclusion No explicit policy to expanding and deepen health protection Need to clarify role of public hospitals and definition of charity beds N0 clear policy on the payor roles of government and PhilHealth SHI has probably increased public spending on health in absolute terms, but has made no difference to % total spending from public sources Heavy reliance on out-of of-pocket remains unchanged Growth in real per capita spending coming more from private than public sources with a slow shift of public spending towards the demand- side SHI does not seem to have triggered an expansion/improvement of hospitals/health facilities
26 Conclusion Current design of benefits fuels inflation with the traditional action of increasing benefit ceilings possibly leading to no, or o minimal, improvements in financial protection The poor are being enrolled into the SHI but PhilHealth provides very limited financial protection for patients with serious illness, and fails to break the link between illness and poverty BUT, PhilHealth recently launched LEAPING FourWARD towards FINANCIAL PROTECTION PROVIDER PAYMENT CONTRACTING with HOSPITALS PREFERENTIAL TREATMENT of PUBLIC HOSPITALS and PHYSICIANS EXPANDED OUT-PATIENT/ OP MEDICINE BENEFIT
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This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
BETTER INFORMED. BETTER TOGETHER.
BETTER INFORMED. BETTER TOGETHER. easy to get appointments free to focus on my patients excellent prenatal care test results online I can choose my doctor wide range of specialists I m part of the decision
Chapter XI. Facility Survey of Providers of ESRD Therapy. ESRD Units: Number and Location. ESRD Patients: Treatment Locale and Number.
Annual Data Report Facility Survey of Providers of ESRD Therapy Chapter XI Annual Facility Survey of Providers of ESRD Therapy T Key Words: Dialysis facility VA facilities ESRD network facilities Hemodialysis
EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan
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State of New Jersey Aetna Medicare SM Plan (PPO)
PLAN FEATURES Deductible (per calendar year) Network Providers $0 Deductible Member Coinsurance N/A Applies to all expenses unless otherwise stated. Annual Maximum Out-of- $1,000 Pocket Amount (includes
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Schedule of Benefits-EPO [Plan Information] [Health Plan:] [Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan] [Primary Member:] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]
KY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
Medicaid Supplemental Hospital Funding Programs Fiscal Year
Fiscal Year 2014-2015 General Revenue Grants and Donations Trust Fund Medical Care Trust Fund Total Rural Proportional Primary Care Hospitals Trauma Level I Trauma Level II or Pediatric Trauma Trauma Level
MEDICARE CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS.
ine 1-800-544-0088 www.care1st.com CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS MEDICARE 2009 COUNTIES: LOS ANGELES - ORANGE - SAN BERNARDINO - SAN DIEGO H5928_09_004_SNP_SB 10/2008 Section I Introduction