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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
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Outline
• Overview of Health System And Health Care Financing
• Current Efforts
• Challenges
• Future Directions
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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
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11%
15%
9% 53%
10%
2%
National Government
Local Government
Social Insurance
Out of Pocket
Private Sector
Foreign Funding
Health Care Expenditure 2010
Source:NCSB
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Health Care Financing Flow
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Current Status of TB in the Philippines
• 15th high burden countries in the world (Global TB Report
2012)
• Prevalence 4.7/1000 (NTPS 2007)
• MDRTB 3.9/1000 (NTPS 2007)
• 8th leading cause of morbidity (FHSIS 2009)
• 25% with TB did not consult any provider (FHS 2011)
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Treatment Success Rate 2011
Source: NTP
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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
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Universal Health Care
Financial
Risk
Protection
Improving
Access to
Quality
Health
Facilities
Attainment of
MDGmax
Better health
outcomes
Responsive health
system
Equitable &
sustainable health
financing
Health
Financing
Service
Delivery
Policy,
Standards and
Regulation
Health
Human
Resource
Health
Information
Governance
for Health
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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
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PhilHealth Financing TB
Preventive: BCG
vaccine for Newborns
TB Screening
and Diagnosis
TB DOTS Treatment
Screening and
Diagnosis for DRTB
Treatment for DR TB
In-patient Admission
PCB 1 Package
(Capitation)
TB DOTS Out-patient
Package (new Cases)
(Case Rate)
In-Patient Benefit (Fee for Service )
Newborn Care
Package (Case Rate)
Vaccine thru EPI
Supplies thru NTP
Meds and supplies thru NTP
Supplies/ capital outlay
thru NTP
Meds and Supplies thru NTP
DOH owned
hospitals
PhilHealth
DOH
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• Qualified dependents of members
• No limit as to number of births
Who can avail
• Non-hospital facilities
• Maternity and Lying-in Clinics
• Hospitals Who provides
• Newborn care
• Screening tests – newborn screening and hearing
• Vaccination – hepatitis B and BCG • EINC protocol
What services
• P 1,750
• No balance billing
Important Features
Newborn Care Package
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• Sponsored Program – NHTS and LGU Sponsored
• Organized Group
• Overseas Workers Program
Who can avail
• Rural Health Centers
• Health Centers
• Out Patient Department of Government Hospitals
Who provides
•Primary Preventive Services-
•Diagnostic Examinations – including sputum examination •Medicines for Common diseases
What services
•Assignment and enlistment of PhilHealth member to Primary Care Provider
• Individual Health Profile – including symptoms suggestive of TB •Electronic reporting with additional incentives
Important Features
Primary Care Benefit 1 Package
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• Members and qualified dependents Who can avail
• TB DOTS Centers (RHUs, private clinics, OPDs of hospitals) Who provides
• Service fee
• Drugs and medicines
• Follow – up sputum smear What services
• P 4,000 Important Features
TB DOTS Package
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• Members and qualified dependents Who can avail
• hospitals Who provides
• Room and board
• Professional fees
• Medicines and supplies
• Laboratory and other diagnostics
What services
• For admissions only
• Case rate and fee for service
Important Features
In –Patient Benefits
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Challenges
• 53% of towns and cities have accredited TB DOTS facilities
• Low utilization
• Incomplete claims – defaulters?
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Number of PhilHealth Engaged TB DOTS Providers
8 29108
385474
627709
813
1090
1201
0
200
400
600
800
1000
1200
1400
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
PCB Providers 2138
Source: PhilHealth AD
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0 0.291.55
6.57.17
20.2
25.50
28.3929.39
12.15
0
5
10
15
20
25
30
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
In m
illio
ns o
f p
eso
s
Year
TB DOTS Package Reimbursement
Note: partial data for 2012
Source; PhilHealth TFI
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Source: PhilHealth TFI
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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
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Health Care Financing Flow
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Health Care Financing Flow
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