PhilHealth TB DOTS Out-patient Benefit Package WHO Consultation Eliminating the Catastrophic Economic Burden of TB: Universal Health Coverage and Social Protection Opportunities April 29, 2013 Sao Paulo, Brazil Dr. Mary Antonette Yason Remonte MDG Benefit Products Team Head Philippine Health Insurance Corporation
Outline Overview of Health System And Health Care Financing Current Efforts Challenges Future Directions
Health Care In the Philippines Large informal sector Highly decentralized Free market Large private sector Cost of services unregulated Out of Pocket expense remains high
Health Care Expenditure 2010 53% 10% 2% 11% 15% 9% National Government Local Government Social Insurance Out of Pocket Private Sector Foreign Funding Source:NCSB
Health Care Financing Flow
Current Status of TB in the Philippines 15 th high burden countries in the world (Global TB Report 2012) Prevalence 4.7/1000 (NTPS 2007) MDRTB 3.9/1000 (NTPS 2007) 8 th leading cause of morbidity (FHSIS 2009) 25% with TB did not consult any provider (FHS 2011)
Treatment Success Rate 2011 Source: NTP
2010-2016 Philippine Plan of Action to Control Tubeculosis Localized implementation of TB Control Monitor health system performance Engaged both public and private providers Promote positive behavior of commmunities Address MDR TB, TB-HIV, and vulnerable populations Regulate and make available diagnostic tests and drugs Certify and accredit TB care providers Secure adequate funding and improve allocation and efficiency of fund utilization
Universal Health Care Better health outcomes Responsive health system Equitable & sustainable health financing Financial Risk Protection Improving Access to Attainment of Quality MDGmax Health Facilities Health Financing Service Delivery Policy, Standards and Regulation Health Human Resource Health Information Governance for Health
Universal Health Care Financial Risk Protection Enrollment of the poor to SHI by the National Government (5 million thru NHTS-PR) Coverage of catastrophic cases (Z benefits) No balance billing policy for the poor Access to quality health services Health facilities enhancement 1,178 RHUs upgraded Attainment of health related MDG goals Focus on MCP, NCP, TB DOTS
PhilHealth Financing TB Newborn Care Package (Case Rate) PCB 1 Package (Capitation) PhilHealth TB DOTS Out-patient Package (new Cases) (Case Rate) In-Patient Benefit (Fee for Service ) Preventive: BCG vaccine for Newborns TB Screening and Diagnosis TB DOTS Treatment Screening and Diagnosis for DRTB Treatment for DR TB In-patient Admission Vaccine thru EPI Supplies thru NTP Meds and supplies thru NTP DOH Supplies/ capital outlay thru NTP Meds and Supplies thru NTP DOH owned hospitals
Newborn Care Package Who can avail Qualified dependents of members No limit as to number of births Who provides What services Important Features Non-hospital facilities Maternity and Lying-in Clinics Hospitals Newborn care Screening tests newborn screening and hearing Vaccination hepatitis B and BCG EINC protocol P 1,750 No balance billing
Primary Care Benefit 1 Package Who can avail Sponsored Program NHTS and LGU Sponsored Organized Group Overseas Workers Program Who provides Rural Health Centers Health Centers Out Patient Department of Government Hospitals What services Primary Preventive Services- Diagnostic Examinations including sputum examination Medicines for Common diseases Important Features Assignment and enlistment of PhilHealth member to Primary Care Provider Individual Health Profile including symptoms suggestive of TB Electronic reporting with additional incentives
TB DOTS Package Who can avail Who provides Members and qualified dependents TB DOTS Centers (RHUs, private clinics, OPDs of hospitals) What services Important Features Service fee Drugs and medicines Follow up sputum smear P 4,000
In Patient Benefits Who can avail Members and qualified dependents Who provides hospitals What services Important Features Room and board Professional fees Medicines and supplies Laboratory and other diagnostics For admissions only Case rate and fee for service
Challenges 53% of towns and cities have accredited TB DOTS facilities Low utilization Incomplete claims defaulters?
Number of PhilHealth Engaged TB DOTS Providers 1400 PCB Providers 2138 1200 1000 1090 1201 800 600 400 385 474 627 709 813 200 108 0 8 29 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: PhilHealth AD
In millions of pesos TB DOTS Package Reimbursement 30 28.39 29.39 25 25.50 20 20.2 15 10 5 6.5 7.17 12.15 0 0.29 1.55 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Note: partial data for 2012 Year Source; PhilHealth TFI
Source: PhilHealth TFI
Future Directions Simplified accreditation approach PhilHealth Engagement thru Accreditation & Contracting of Health Services Automatic Accreditation, decentralization Increased coverage of the poor Sin Tax Law premium for next quintile Increase coverage for the TB conditions Category II to be included in TB DOTS Package MDRTB for study Improved quality of care payment upon completion of treatment Quality standards for out-patient facilities on the works
Health Care Financing Flow
Health Care Financing Flow