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The Philippine Health Insurance Corporation (PhilHealth) was created in

1995 to
create a universal health coverage for the Philippines. It is a tax-exempt,
government-owned and government-controlled corporation (GOCC) of the
Philippines, and is attached to the Department of Health. It states its goal as
insuring a sustainable national health insurance program for all.
[1]
In 2010, it
claimed to have achieved "universal" coverage with 86% of the population,
although the 2008 National Demographic Health Survey showed that only 38
percent of respondents were aware of at least one household member being
enrolled in PhilHealth.
[2]
Nevertheless, this social insurance program provides a
means for the healthy to pay for the care of the sick and for those who can afford
medical care to subsidize those who cannot. Both local
[3]
and national
government allocate funds to subsidize the indigent.
[4]

Contents
[hide]
1 Mandate and Functions
2 Funding and Revenues
3 Patient groups
4 Coverage
5 Benefits
6 Service delivery system
7 Structure
8 Provider Payment Mechanism
o 8.1 Quality
o 8.2 Performance-based Payment
o 8.3 Claims Processing
9 Monitoring and Evaluation
10 Fraud and Controversies
11 History
12 References
13 External links
Mandate and Functions[edit]
In 2000 and 2005, reform efforts were outlined to make decentralization and
health insurance work more effectively, including an expanded government
subsidy for the enrollment of the poor, the creation of local health service
delivery/planning units to reduce fragmentation, and a stronger DOH role in
regulation.
[5]

PhilHealth has four categories of enrollees encompassing nearly the entire
population. The "formal" sector is for workers employed by companies and other
institutions. Indigents have no means of support. Retirees (non-paying members)
have already paid premiums for 120 months of membership and are 60 or older.
The individual paying program (IPP) is for those not eligible for the other three
categories. Although treated separately, the Overseas Filipino Workers (OFW)
program can be considered as part of the IPP category.
Since 1996, the benefits package and delivery system have improved. For
example, PhilHealth now has an Outpatient and Diagnostic Package limited to
indigent enrollees. This addition creates nearly comprehensive coverage for
indigents. All other beneficiaries have access to nearly comprehensive services,
excluding some outpatient care. PhilHealth introduced an accreditation program
for private hospitals.
Some key reform indicators to date include:
Estimated coverage is 70% as of June 2013
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 as of December 1, 2009, implemented a simplified
reimbursement scheme wherein 75% of the claims amount 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.
[6]

Funding and Revenues[edit]
Funding varies based on the population covered, although the majority of funds
flow from general taxation. Premiums for the formal sector reach up to 3% of
monthly income. Premiums for both the poor and the informal sector are 1,200
pesos annually (about 25 USD). However, the cost of insurance for the poor is
fully subsidized by the central and local governments. The National government
allocates more than 9 billion pesos annually to meet its target.
[7]

Patient groups[edit]
Program summary
[8]

Group Premiums Enrollment Payment
Formal
Employer and worker
each pay half, up to 2.5%
(maximum of 3%) of
income up to 30,000
pesos
As of hire date 3 months
Indigent 2,400 pesos annually
National
Government fully
subsidizes
enrollment annually.
None
Retiree Free
Age 60 with 10
years of premium
payments

Individually
Paying
1,800 pesos annually for
members earning
P25,000 and below
3,600 pesos annually for
members earning more
than P25,000
Enrollment date.

OFW
(Landbased)
1,200 pesos annually Emigration date
No subsidy.
Payment is on
emigration date
then annually.
All premiums are pooled nationally and in effect, there is cross-subsidization
across districts. National government payment is dependent on the availability of
funds.
Coverage[edit]
The benefits package is essentially the same for each group. The exception is for
indigents and the 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[edit]
PhilHealth beneficiaries have access to a nearly comprehensive package of
services, including inpatient care, catastrophic coverage, ambulatory surgeries,
deliveries, and outpatient treatment for malaria and tuberculosis. Those identified
as indigent and OFW are also entitled to outpatient primary care.
Inpatient care includes room and board, medicines, diagnostic and other
services, professional fees and operating room services. These benefits are
subject to some limits, which differ based on the level of the health
facility/hospital (level 1 to 4 hospitals and the Ambulatory surgical centers
equivalent to level 2 hospitals) and the severity of the cause of admission (case-
type A, B, C and D). Catastrophic conditions, ambulatory surgeries
including ambulatory dialysis, deliveries and outpatient malaria and TB-DOTS
care.
Except for the outpatient primary care that the poor and OFWs are entitled to via
public providers, patients have free choice of providers, both public and private.
Annual or lifetime coverage limits exist. These limits are expressed in terms of
volumes of services (e.g., days) rather than a peso coverage limit. For example,
households are eligible for 45 days of inpatient admission, sharing 45 days
among all household members. Each day of ambulatory surgery counts as a day
of admission.
Providers are allowed to charge the patient the difference between the total cost
of care and what PhilHealth pays (i.e., balance billing).
Service delivery system[edit]
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[edit]
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-Chairman. 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", the President and CEO of
PhilHealth now has a term of one (1) year (Section 17, RA 10149) to be elected
among the ranks of the Board of Directors and subject to the disciplinary powers
of the Board and may be removed for cause (Section 18, RA 10149).
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 years premium and 3% of the income of the fund it manages towards
operating expenses.
Congress mandated that the National Institutes of Health (based in the University
of the Philippines) to conduct studies to verify and validate performance.
Provider Payment Mechanism[edit]
Provider payment methods differ based on the type of care delivered. Fee-for-
service reimbursements are used for inpatient care, most day surgeries, and
ambulatory procedures, while primary care providers are reimbursed based on a
capitation system. For TB-DOTS treatment, malaria care, deliveries, surgical
contraception, and cataract surgeries, a case-based payment methodology is
utilized.
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[edit]
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, hospitals accreditedation is good 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 as of December 2009.
Performance-based Payment[edit]
PhilHealth has been developing incentive payments focused on payment to
health care professionals. Doctors are usually independents 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 PhilHealths 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[edit]
Claims processing is manual. Hospitals or members fill out claim forms that are
then submitted to PhilHealth within 60 days from hospital or health facility
discharge. Two forms are usually submitted: One documents the member and
premiums paid. The other details the service provided. 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 not implemented.
Monitoring and Evaluation[edit]
PhilHealth conducts its own monitoring and evaluation, though the law mandates
that the 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.
Fraud and Controversies[edit]
In 2011 fraudulent claims against the state-health insurer were estimated at 4
billion pesos. It failed to prosecute erring doctors and hospital. AFP Medical
Center, St. Lukes Hospital, Philippine Orthopedic Hospital, University of Sto.
Tomas Hospital, East Avenue Medical Center, Cardinal Santos Medical Center,
Medical City, National Kidney, General Santos District Hospital (GSDH) and
Transplant Institute were investigated for health insurance fraud.
[9]
In Iloilo, eye
doctor claims 2, 071 operations amounting to P16 million professional fees in
2006. A hospital in Davao City notice that a janitor lying in bed and claiming to be
a PhilHealth accredited patient.
[10]
In 2006 PhilHealth revoked the accreditation of
Sara Medical Clinic in Midsayap for ghost patients.
[11]

History[edit]
The Philippine Medical Care Program began in 1971 following the Philippine
Medical Care Act of 1969.
[12]
It mandated creation of the Philippine Medical Care
Commission (PMCC). In 1990 bills 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 President Fidel Ramos on February 14, 1995. This become the
basis of the Philippine Health Insurance Corporation.
[13]
On its 16th anniversary
the song "PhilHealth: Tapat na Serbisyo, Tapat na Benepisyo, Lahat Panalo"
was introduced.
[14]

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