financing of hospital services (2)[1]

8/4/2019 Financing of Hospital Services (2)[1]

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FINANCING OFHOSPITAL SERVICES

By:

MA. CORAZON AZURIN PRECILLA

Submitted to:

DR. FELCEDA CABANOS


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FINANCING OF HEALTH SERVICES

HEALTH CARE EXPENDITURESHealth care expenditures contributed 3.6% of

the countrys Gross Domestic Product (GDP) in 1995,

below the 5% standard set by the World HealthOrganization (WHO) for developing countries. GDP

refers to the market value of all final goods and services

produced within country in a given period of time. It is

often considered an indicator of a countrys standard of

living.

While there exists a national insurance

program, pension funds and private insurance plans,

personal expense, or out of pocket (OOP)

expenditures still accounted for about 47% of all health

expenditures in 1997 and even rose to 54% in the year

2007. The annual health expenditure in the Philippinesamounted from P87.1 Billion in 1997 to P234.3 Billion in

2007.

The governments goal is to increase the share

in expense of social insurance from 5%of the total health


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expenditures to 30%. However, the social insurances

share as of the year 2007 has grown only by 4%, from 5%

in 1997 to 9% in 2007, falling short of the governmentsgoal by 21%.

In 1995, Republic Act No. 7875, an act instituting

a National Health Insurance Program (NHIP) for all

Filipinos and establishing Philippine Health Insurance

Corporation (PHIC), was passed in 1995. Since then,social insurance is the responsibility of the PHIC which

assumed administration of the pension funds for both

private and government employees since 1998.

All Filipino citizens, whether self-employed,

employed or indigents are required to becomemembers before they can avail of the benefits or

reimbursements for medical services. This is done

through automatic salary deduction or direct payments

to Philhealth. Aside from this, Filipinos have the choice

to become members of life insurance companies of

health management organizations (HMOs).

In general, healthcare financing in the

Philippines call for improvement. While the public

health system was decentralized to local government

units (LGUs), this only lead to inequitable distribution of

health services.


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MAJOR PROBLEMS IN HEALTH FINANCING

Regardless of whether a hospital is owned by the

government of a private entity, it still requires money tooperate it. More often than not, finances become a major

problem or set back in the operational system of a hospital.

The following are the major problems in financing health

services:

1. Lack of funds.

This inadequacy may be absolute, in which case, it can

be corrected only by the infusion of additional

resources. This may be done any of the folllowing:

For government run hospitals: Additional funding from other government units.

Additional funding from donors (private entities,

individual donors, foreign aid, etc.)

For private hospitals:

Increase in capitalization.

Advances from stockholders (additional equity).

Obtaining loans from lending institutions like banks.


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Another inadequacy is called relative. This

inadequacy may be corrected by the followingschemes:

Better use of existing resources.

Mobilizing previously untapped resources.

Redirecting funds from other sectors.

In our hospital, we enjoin our consultants to tell

their patients to have their laboratory and other

diagnostic tests done in our hospital instead of the

patients going to other diagnostic centers. This way, we

maximize the use of our existing machines and

equipment and manpower as well.

Sadly, there are employees who are not very

productive. Stricter measures, close monitoring and

proper motivation can be done to tap these

employees skills. In so doing, we maximize the use of

our people and reduce cost by not having to hireadditional personnel.


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Redirecting of funds from other sectors such as from

the national to the local government is another way toalleviate this inadequacy. Funding from other non-

governmental agencies like the Philippine Charity

Sweepstakes Office (PCSO) or the Philippine Amusement

and Gaming Corporation (PAGCOR) is a big help to our

government hospitals.

The Philippine General Hospital (PGH) does not rely

solely on government funding. It has a foundation who

solicits funding from philantrophists, companies or

corporations or other foundations. It also engages in

different fundraising events like golf tournaments, artauctions, fashion shows, concerts and the like.

2. Maldistribution of health care costs.

Maldistribution of health care costs may be one of twothings:

Geographical maldistribution happens when most of

the expenditures is on urban health services and only a

small portion is alloted to rural or remote areas.


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Functional maldistribution could happen in a

market economy where wealth determines the

volume of care rather than the real healthneeds. This also happens in situations of

compulsory social insurance schemes covering

only a small minority of the population, where

services are very good while for the rest are

wanting.

3. Rising health care costs.

Rising health care costs from rising public

expectations, qualitative and quantitative

concomitant with rapid technologicaldevelopments in the health field require more

investments on the part of the hospital.

Obtaining licensures or accreditation is one

good example. The benchmarking by the

Department of Health (DOH) required our

hospital to purchase somemachines/equipment. This put a great cost in

our hospitals finances.


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Benchmarking is the process of identifying "best

practice" in relation to both products (including)

and the processes by which those products are

created and delivered. The search for "best

practice" can take place both inside a particular

industry, and also in other industries. The

objective of benchmarking is to understand and

evaluate the current position of a business or

organisation in relation to "best practice" and to

identify areas and means of performanceimprovement.

Rising health care costs may be caused by the rising

cost of living which inevitably raises the cost of

health care. Basic needs like electricity and water

are very expensive. Prudent use of these should be

properly observed to help cut down costsT

Rapid technological developments in the health

field not only in terms of machines, but also of

highly skilled personnel, require more investments.


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4. Lack of coordination.

In most countries, health care financing isderived from different resources. Within the

government, problems of coordination may

be observed between the national and local

government units (LGUs). Coordination may

also be a problem in the use of foreign aid

wherein different instrumentalities of

government are unable to provide the

necessary participation in the actual

execution and in putting up counterpart

funds as may be required.

In private hospitals, lack of coordination can

happen between departments. Wastage

and/or spoilage that can result from this will

cost money for the hospital.


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5. Inefficiencies in spending (mismanagement of

funds).

Overstaffing and/or misuse of manpower.

Misuse of expensive health equipment.

Use of unnecessary or inappropriate

technology.

Management and administrative deficiencies.


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APPROACHES TO IMPROVE FINANCING

It is important to know or recognize

that health financing problems are not simplyhealth sector problems. They often reflect

economy-wide difficulties. They require

national strategies to address them even where

additional resources are to be recruited by

actions within the health sector and that

resources can be re-allocated within the sectorto meet priority health needs, in order to justisy

financing strategies.

The World Health Organization (WHO)

Technical Report Series 625 listed the followingapproaches.


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1. Extending existing sources of funds.

Through more efficient collection of

taxes/contributions.

General tax revenue is used in almost every

country to finance certain components ofhealth care in developing countries.

However, it is not the most reliable source of

finance for the health sector. This results

from factors such as the low political priority

frequently given to the health sector in

national budget decisions.

Through increasing taxes and employee-employer

share.

An increase in employee/employer share incompulsory health insurance is another approach.

The following is the current table of contributions

from Philhealth:


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The premium paid by voluntary

members was recently upped fromP100.00/month to P200.00/month.

2. Devolping new sources of revenues such as

introducing new tax laws and earmarking for

health, portions of certain specific taxes already

being enforced.

Value added tax (VAT) imposed by the Bureau

of Internal Revenue.

There are also the excise taxes otherwiseknown as sin taxes, imposed on cigarettes

and liquor. The consumption of tobacco and

alcohol contribute to health care costs for a

number of diseases brought on by it which

impose significant costs on health care

systems.


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3. Extending/introducing social security

systems (health insurance).

Private health insurance differs from social

insurance in 2 main ways. First, private

health insurances typically does not

include pensions for invalidity or old age.

Secondly, the price (premium) charged

for private health insurance is not basedon the pooled risks of a large population,

but on personal risk characteristics and

the likelihood of illness in the individual or

group covered.

Social insurance can finance health care,

as well as other needs such as invalidity

and old age support, for either the whole

population or a part of it. It is financed by

imposing mandatory insurance payments

on employed workers and a somewhathigher part from the employers.


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4. Encouraging community contributions or in kind,

organization of health cooperatives (self-help).

Current primary health care initiatives in

developing countries stress the importance of

national self-reliance and community

participation in health care delivery. Bymobilizing under-utilized national and local

resources (e.g. organizational skills manpower

and cash) and by developing affordable and

cutlturally appropriate delivery systems, it is

hoped that basic health care will become

universally acccessible. Consequently, somegovernments and many non-governmental

agencies are turning to communities for

organization, participation and financial

support, and communal self-help is increasingly

thought of as an important source of financialsupport for health services in developing

countries. The challenge is to develop new

types of local institution that can coordinate

and systematically utilize the community

resources. Self-help can take many froms such

as labor, local insurance for volunteer healthworkers and drug cooperatives.


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5. Increasing the efficiency in the allocationand actual use of resources. The hospital

should give priority to its basic and

essential needs and study how its activities

can better be carried out.


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SCHEMES OF HOSPITAL SERVICES FINANCING

Hospital services are supported by one

or a combination of schemes, namely:

1. Public subsidy.

This is a form of financial assistance paid

to a business or economic sector. In this

scheme, the source of funds is from

taxes. These may come from different

levels of government-national,

provincial/city and local, withagreements on how the cost of hospital

services is to be shared.


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2. Private grants/endowments.

Grants are funds disbursed by one party ,

often a government department,

corporation, foundation or trust, to a

recipient, often (but not always) a non-

profit entity.

Endowments are transfers of money orproperty donated to an institution.

Philantrophic individuals or organizations

may provide grants/endowments to

construct, expand or improve hospitals.

Endowments may also be used to afford

indigent patients prompt and necessary care

in hospitals. The Philippine Charity

Sweepstakes Office (PCSO) is one of the

more known giver of endowments.


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3. Hospital receipts/income.

The payment for professional and hospital

services rendered to a patient may come

directly from himself (out-of-pocket), from

the employer, or from third party schemes.

Out of pocket (OOP) payment.

The payment is generally referred to as

user charges. This type of financing issuitable if the patient is willing and in a

financial position to pay on a fee-for-

service basis.


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Employer-provided health benefits.

Apart from the usual social security

scheme and employee compensation scheme,

employers may provide medical benefits

including payment for professional services and

cost of hospitalization as part of their collective

bargaining agreement.


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y Third party schemes.

Third party schemes may refer to

employees compensation scheme, and

health maintenance organizations

(HMOs) and health insurance.

o Employees compensation scheme.

In certain countries, aside from the usual

health insurance required by the country,

another scheme is established for work-

related sickness, injury disability, or evendeath. The beneficiaries are the

employees themselves and their

dependents.


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o Health Maintenance Organizations

(HMOs)

This organization is a system of health care

that guarantees to provide high quality

physician services, emergency and

preventive treatment, and hospital services

to individuals who have agreed to obtain

their medical care from the HMO for anextended period of time. In return, the

individuals pay a fixed annual sum in

advance.

Note should be taken that the HMO issupposed to guarantee high quality service

in contrast with health insurance which

guarantees financial reimbursement or

payment only.


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o Health Insurance

Health insurance is insurance againstthe risk of incurring medical expenses

among individuals. By estimating the

overall risk of health care expenses

among a targeted group, an insurer can

develop a routine finance structure,such as a monthly premium or payroll

tax, to ensure that money is available

to pay for the health care benefits

specified in the insurance agreement.

The benefit is administered by a central

organization such as a governmentagency, private business, or not-for-

profit entity.


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3 Elements Necessary to Develop and

Sustain a Health Insurance:

Population awareness of the need for healthinsurance, understanding of its purpose and

general operation, and possessing the right

attitude towards the insurance, having a sense

of ownership for the scheme and therefore

with motivation to protect it.

The National Health Insurance Act of

1995 Republic Act No. 7875 states the

following objectives of PHIC as:

a. provide all citizens of the Philippineswith the mechanism to gain financial

access to health services;

b. establish the National Health

Insurance Program (NHIP) to serve as

the means to help the people pay for

health care services; and

c. prioritize and accelerate the

provision of health services to all

Filipinos, especially that segment of

the

population who cannot afford theseservices.


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Availability and responsiveness of the health care

delivery system to adequately attend to the

medical care needs of the members of theinsurance scheme.

Section 5 of Republic Act No. 7875 lists the

following as eligible to be members:

1. Employed1.1 Government Sector

1.2 Private Sector to include household help and

sea-based OFWs

2. Individually-Paying

2.1 Self-Employedy All self-employed professionals

y Partners and single proprietors of businesses

y Actors and actresses, directors, scriptwriters

and news correspondents who do not fall

within the

y definition of the term employee in Section3n of this Rules

y Professional athletes, coaches, trainers and

jockeys, and

Individual farmers and fisherfolks


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2.2 Land-based OFWs

2.3 Privately sponsored/employed to include

employers/employees of international

organizations and

foreign governments based in the Philippines

2.4 Others including but not limited to the

following: Individuals who are separated from

employment

Parents who are not qualified as legal

dependents, indigents or retirees/pensioners

Children who are not qualified as legal

dependents

Unemployed persons who are not

qualified as indigents

Citizens of the Philippines residing in

other countries

Citizens of other countries residingand/or working in the Philippines


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3. Enrolled Indigents

4. Retiree-Members

4.1 Old-age retirees and pensioners of the GSIS,

including uniformed and non-uniformedpersonnel of

the Armed Forces of the Philippines (AFP),

Philippine National Police (PNP), Bureau of Fire

Protection (BFP) and the Bureau of Jail

Management and Penology (BJMP) who havereached the

compulsory age of retirement before June 24,

1997, and retirees under Presidential Decree

408;

4.2 GSIS disability pensioners prior to March 4,

1995;4.3 SSS pensioners prior to March 4, 1995:

4.3.1 SSS permanent total disability pensioners;

4.3.2 SSS death/survivorship pensioners;

4.4 SSS old-age retirees/pensioners;

4.5 Uniformed members of the AFP, PNP, BFPand BJMP who have reached the compulsory

age of

retirement on or after June 24, 1997, being the

effectivity date of RA 8291 which excluded said

individuals in the compulsory membership of

the GSIS;4.6 Retirees and pensioners who are members

of the judiciary;


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4.7 Retirees who are members of

Constitutional Commissions and other

constitutional offices;4.8 Former employees of the government

and/or private sectors who have

accumulated/paid at least

120 monthly premium contributions as

provided for by law but separated from

employment beforereaching sixty (60) years old and thereafter

have reached age sixty (60);

4.9 Former employees of the government

and/or private sectors who were separated

from employmentwithout completing 120 monthly premium

contributions but continued to pay their

premium

PhilHealth IRR 2004 11

payment as individually-paying members

(IPM) until completion of the required 120monthly

premium contributions and have reached

age sixty (60) as provided for by law;


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4.10 Individually-paying members (IPM),

including SSS self-employed and voluntarymembers, who

continued paying premium contributions to

PhilHealth, have reached age sixty (60) and

have met the

required 120 monthly premium contributions

as provided for by law; and

4.11 Retired underground mine workers who

have reached the age of retirement as

provided for by law

and have met the minimum required premium

contributions.


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Availability of organized administrative

structure and system for efficient collection of

premiums, the processing and payment ofclaims, and the facility to examine providers

credentials and performance.

SECTION 55 of RA 7875 states the

Specific Accreditation Requirements

and Conditions for Hospitals:

In addition to the general requirements

and conditions prescribed in this Rules,

hospitals shall comply with the

following specific requirements andconditions for accreditation:

a. It must be licensed by the DOH;

b. It must comply at all times with the

provisions of Republic Act 4226,

otherwise known as The Hospital

Licensure Act, and its prevailing

Implementing Rules and Regulations as

well as other applicable

administrative issuances;


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c. It must be a member in good standing of any

national association of licensed hospitals in thePhilippines

duly recognized by the Corporation in

accordance with its established standards and

criteria;

d. All secondary hospitals must establish a

Therapeutic Committee and other committeesthat will ensure

rational drug use; and

e. All tertiary hospitals must establish

Therapeutics and Infection Control Committees

and other committeesthat will ensure rational drug use.

SECTION 52. Health Care Providers

The following health care providers shall be

accredited before they can participate in theNHIP:

a Institutional Health Care Providers


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a. Institutional Health Care Providers

Hospitals

Out-Patient Clinics

Health Maintenance Organizations(HMOs)

Preferred Provider Organizations (PPOs)

Community-Based Health Care

Organizations (CBHCOs)

Other institutional health care providers

licensed by the DOH

a. Independent Health Care Professionals

Physicians

Dentists

Nurses Midwives

Pharmacists

Other duly licensed health care

professionals

Health care professionals under the

employment of accredited institutionalhealth care providers must be

accredited individually when receiving

from the NHIP separate reimbursement

for rendering health services,

whether or not such services are renderedindependent of their institutions.


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ADVANTAGES OF HEALTH INSURANCE

It protects against the catastrophic cost ofillness through the principle of risk sharing.

Risk sharing is a management method in

which the cost of the consequences of a risk is

distributed among several participants.

It makes health care cost affordable to awider segment of the population. It collects

small contributions (premium) from members

on a regular basis which is an assurance of

financial assistance if the time comes.

It is an effective means of generating

resources for health services. The

government, the private sector, and the

citizenry are compelled to set aside money for

health purposes.

In some countries, the social securityagencies may (a) construct and

operate their own hospitals; (b)

construct a hospital and let the

government staff manage it; or (c)

contract an existing hospital to

provide services to its members.


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WAYS BY WHICH HEALTH INSURANCE EFFECT

PAYMENT FOR SERVICES

Direct reimbursement to the member. This

means that the member will have to spend

his own money first and then claim for

reimbursement later.

Payment to the hospital. Hospitals affiliated

with the health plan bill directly the

insurance company, and whatever is not

within the companys responsibility is in turn

shouldered by its member.

Payment or reimbursements

are computed according to the final

diagnosis given to the member. An

illness may be categorized as either

ordinary, intensive or catastrophic.

There are certain limits for eachcategory.


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WAYS OF SHARING EXPENSES BETWEEN THE

SOCIAL SECURITY SCHEME AND THE MEMBER

A ceiling for total hospital expenditures

may be established within which the

scheme pays for everything, and beyond

which, the member pays. Ceilings may

also be fixed for hospital acocommodation

(number of days in the hospital, expenses

for laboratory, x-ray, operations,

professional fees, etc).

Employees compensation scheme. In

certain countries, another scheme isestablished specifically for work-related

sickness, injury, disability or even death.

The beneficiaries are the employees and

their dependents. The contribution to the

scheme is given by the employer only.


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Health maintenance organizations (HMOs).

This organization is a system of health carethat guarantees to provide high quality

physician services, emergency and preventive

treatment, and hospital services to

individuals who have agreed to obtain their

medical care from the HMO for an extendedperiod of time. In return, the individuals pay

a fixed annual sum in advance. Note should

be taken that the HMO is supposed to

guarantee high quality service in contrast

with the usual health insurance which

guarantees financial reimbursement orpayment only. It will be, observed that

because of the nature of the guarantee, the

HMO must maintain its own list of physicians,

hospitals or clinics which can provide high

quality care readily and must have come toan arrangement with them on the rates of

charges or payment to be made by the HMO

to them.


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According to the organization of health careproviders it maintians, HMOs may be

classified into two, namely:

Prepaid group practice, in which the HMO

engages physicians working at a single site as agroup and having some kind of working

relationship with a hospital.

Individual practice association in which doctors

continue to work out of their own offices andare enrolled with the HMO which pays them on

a fee-for-service basis.


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According to ownership, HMOs may

be classified into three:

Investor based. The HMOs in this categoryare private organizations offering their

products to prospective clients at large. It

may be owned by business investors or by

groups of medical practitioners.

Community based. These are like investor-

based HMOs, the services of which are

offered to specific communities such as a

corporate community or a

geographical/political community, with

members paying monthly fees for aspecified set of benefits, which are usually

of lower levels than those offered by the

investor based.

A very good example of this is a 5th class


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A very good example of this is a 5th class

town in San Isidro, Nueva Ecija. The local

government of San Isidro tapped the

potential of participative governance,integrated social and economic services

and sustained gains of institutionalizing

its health program into the local

government.

The local government allocated 16% of

the municipal budget to health. 36%

came from Philhealth payments and co-

share of beneficiaries and 64% from the

Internal Revenue allotment. This allowed

them to address a barangay-based health

care system while maintaining a client-centered clinic with two doctors, two

nurses, a dentist, two medical technicians,

lab inspectors, five

midwives/nutritionists, a data encoder

and 170 barangay health workers.

Residents of San Isidro contribute

P200/month for health who in turn get

additional benefits from Philhealth. By

having a sense of ownership for the

program through active participation, the

community has managed to sustain thecommunitys health care needs.


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Employer initiated. This type of HMO is

set up/initiated by big organizations for

the benefit of their employees and their

dependents. Usually, these are non-

profit, and the membership fees are

subsidized by the employer.


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HOSPITAL MODES OF PAYMENT

Hospital modes of payment determines

the amount and the flow of money from a third

party payer or patient, or both, to providers of

care in exchange for services. This defines both

the unit or combination of services for which aprovider is paid and the price for the services

provided.

Fee-for-service. This means that per item of

service such as individual acts of diagnosis,

therapy, pharmaceutical services andtreatment, a fee is paid. Professional fees

may or may not be paid separately and this

may differ according to specialization and

category of room occupied in a hospital.


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Case payment. Under this method, payment is

made for a package of services or an episode of

care. Unlike the fee-for-service method, the

payments are not itemized and added.

Capitation. In this system, physicians are paid

for each patient on their list, usually with

adjustments for factors such as age and gender.

This system is used in countries like Italy, UK,

Austria, Denmark, Ireland and Sweden.

Salary. A monthly income is provided regardless

of the workload or cost of services provided.

This method of of payment is the one usually

implemented in government health care

institutions. This also applies for residents

working in private hospitals.

DailyCharge. A flat rate per day is charged for

every patient case hospitalization.


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Bonus payment. Under this method, a direct

payment of an agreed fee is made for a type ofservice provided. This is used in the United

States.

Global budget. In this mode, hospitals are paid

based on an all-inclusive operating budget setin advance but allowing for flexibility in the use

of funds inside the overall limit or spending

ceiling. Global budgets are intended to

constrain both the level and rate of increase in

health care cost by limiting them directly.


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EVALUATION OF THE EFFICIENCY AND EFFECTIVENESS OF THEVARIOUS FINANCING SCHEMES FOR HOSPITALS

Quality Patient Care

Hospital s 2 main Goals

Economic Viability

Whether private of government these two main goals

stand and whether a hospital is for profit or not economic

viability remains to be an all important consideration if the

hospital is to continue rendering service. This is because funds

are getting scarcer and scarcer both for government and privatehospitals. For government decentralization of responsibility for

hospital services to the local government has resulted in

inadequacy of funds for continuous operation of hospitals. Fo

the private hospitals loans for investments have also been

getting scarcer and expensive. Grants and donations have also

been reduced.

Efficiency


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Efficiency

Within the health sector, the first

priority must be to improve efficiency,making better use of available resources

and enhancing the standing of the sector

nationwide. Management can be

strengthened through staff training and

the development of appropriate tools,efforts can be made to understand the

communitys needs in order that health

care better meets them, and resources

can be allocated more appropriately.

In terms of cost recovery, review ofexperiences show that wide variations

exist in the amount of hospital recurrent

costs recovered through user fees but

most public facilities recover only a small

amount.

Effectiveness


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Out-of-pocket (OOP) expenditures and

health insurance with co-insurance or co-payment schemes may be considered to be

the most effective in achieving quality

health care received. This is so because

with the individual responsible or party

responsible for the cost of health care, he

may be on the look-out for the best

services for the protection of his own

welfare. This occurs despite the fact that

he may not be thoroughly and adequately

knowledgeable on the amount and type of

health care he needs.

Community financing may also have

the aforementioned characteristics since

the communities themselves are the ones

managing their health services.


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IMPLICATIONS OF THE VARIOUS FINANCING

SCHEMES WITH THEIR RELATIVE EFFICIENCY

AND EFFECTIVENESS:

The need to minimize the average cost of

treating a case.

The need to be more sensitive to the needs and

preference of the patient. The profit motive should not be the dominant

force in a hospital.


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PAYMENT POLICIES-PUBLIC AND PRIVATE

HOSPITALS

Private Hospitals

1. Advance payment ( as opposed to deposit).

2. Progressive billing.

3. Itemized billing will be provided the patient.

4. Where laboratory or other tests have to bedone outside of the hospital, cost is charged to

the patient, at times, with handling fee added.

5. All medicines and medical supplies are to be

bought in the hospital.

6. Professional fees may be collected by thecashiers as a matter of courtesy to doctors.

7. Private hospitals has the obligation to

administer emergency interventions to the

extent of use of some of their consumable

resources.

Government Hospitals

1. Room and services are free.

2. Professional fees are waived.

3. Medicines, medical supplies and diagnostic

tests are paid by the patient.


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THANK YOU!

financing of hospital services (2)[1]

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