The Philippine Health Insurance Corporation (PhilHealth) was created in 1995 with the aim of placing a renewed emphasis on achieving universal coverage. Categorized as a tax-exempt government-owned and -controlled corporation (GOCC) of the Philippines, and attached to the Department of Health providing affordable health social health insurance coverage for all Filipinos. Insuring the sustainable national health insurance program for all.[1] In 2010 reported that has 86% members far from its target of universal health care coverage to Filipinos.[2] This social insurance program shall serve as the means for the healthy to help 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 subsidy the indigent.[4]
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In 2000 and 2005, additional reform efforts were outlined to make decentralization and health insurance reform 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]
Since PhilHealth’s creation, several developments have occurred in terms of expanding both the breadth and depth of health coverage. In terms of the population coverage, PhilHealth now has four categories of enrollees encompassing nearly the entire population:
Since 1995, several improvements have been made to the benefits package and delivery system. For example, PhilHealth now has an Outpatient and Diagnostic Package limited to indigent enrollees. This new addition creates nearly comprehensive coverage for the indigent category of beneficiaries. All other beneficiaries have access to nearly comprehensive services, as well, excluding some outpatient care.
In terms of the delivery system, since the private sector is a major player in the delivery of health services, PhilHealth has introduced an accreditation program for private hospitals.
In 2000 and 2005, changes were implemented as a series of incremental reforms to improve the existing systems without fundamentally changing how health financing and delivery works in the Philippines.
Some of these incremental reforms include:
Some key reform indicators to date include:
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 incomplete information. 28% of claims were submitted by public providers and 72% by private providers.[6]
Funding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be 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. National government allocate more than 9 billion pesos annually to meet its three-year target.[7]
Funding by population is as follows:
Both national and local governments are responsible for the full subsidy for indigents. A recent policy proposal is for the national government to fully pay the subsidy in order to accelerate the efforts towards universal coverage by enrolling the poorest. However, this proposal has not been approved and the current cost-sharing scheme remains. Currently, the local government identifies and determines who is poor, then enrolls them in the national health insurance program. Once enrolled, the national government is expected to pay its counterpart. The central government cost-sharing percentage depends on the income level of the local government, but on average local governments contribute 25% and the national government contributes 75%.
All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The frequency of premium contributions varies by each population category. For example, formal sector payroll collections naturally occur monthly, while for the non-poor, premium contributions occur based on when individuals seek to enroll. For OFWs, the premium is collected upon departure from the country and then on an annual basis. For the poor subsidized by the government, enrollment occurs annually and the local government pays quarterly while the national government is billed as soon as enough local governments have enrolled their poor. National government payment is dependent on the availability of funds.
Premiums for formal sector are set by law to be up to 3% of the monthly income. However, the current level is 2.5%, applied up to the first 30,000 pesos of income (i.e., all people earning up to or more than 30,000 pesos pay the same premium, while people with salaries under 30,000 pesos pay less). The premium of 1,200 pesos annually for the poor and informal sector has been the same for more than 9 years. The rate for the OFWs was 900 pesos annually until two years ago when it was increased to 1,200 pesos.
PhilHealth coverage is theoretically available to the entire population. The enrollment process differs based on the population group. For example, all formal sector workers must enroll at the start of employment. The poor are identified and enrolled by the local government.[8]
The population is tagged to one of the four major population categorizations:[9]
The benefits package is essentially the same for each population 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.
However, the enrollment process for each population category differs. For the formal sector, employees are enrolled upon the start of employment. It is mandatory that all employees enroll in health insurance. No exceptions are allowed for the size of the company. For the poor, the local government determines “poorness” and enrolls those who are determined poor. For the rest of the population there is open enrollment—one can walk into a local enrollment office anytime to enroll.[10]
While enrollment is mandatory only for the formal sector, for the remain
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.
More specifically, services included range from:
Except for the outpatient primary care that the poor and OFWs are entitled to via public providers, there is free choice of providers for beneficiaries, both public and private.
Annual or lifetime coverage limits do exist. These limits are expressed in terms of volumes of services (e.g., days) rather than a peso coverage limit. For example, member 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.
While there is no formal system that sets fixed deductibles or co-payments, health care providers are allowed to charge the patient the balance between the total cost of care and what PhilHealth pay (i.e., balance billing).
There are some waiting periods before beneficiaries can access care; waiting periods differ by population category:
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.
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 also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of PhilHealth as vice-chairman. The president and CEO have a fixed term of 6 years.
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 year’s premium and 3% of the income of the fund it manages towards operating expenses.
For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth.
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.
There is no formal system that sets fixed 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: 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 the following domains of quality of care: patient rights and organizational ethic, patient care, leadership and management, human resource management, information management, safe practice and environment, and mechanisms of improving performance. With the implementation of the new standards this year, hospitals can now be accredited for up to 3 years compared with the previous practice of annual accreditation. PhilHealth has accreditation staff who physically check and verify compliance. PhilHealth has also set peer review committees essentially composed of health care providers who review specific cases.
PhilHealth has been planning to implement quality-based purchasing but has not executed on this plan as of December 2009[update].
Performance-based Payment: PhilHealth has been developing incentive payments but this work has been focused on payment to health care professionals and not for health facilities. Doctors are usually independent free agents who ‘practice’ in hospitals. Even government physicians who are salaried are allowed to engage in private practice. Thus, PhilHealth payments are split for health professionals and health facilities and efforts to implement case payments essentially focus on bundling the payment for the health facilities.
Among PhilHealth’s work in incentive-based payments is a scheme that has been piloted in 30 local government hospitals since 2002 but has not been scaled up. The scheme is called the Quality Improvement Demonstration Study (QIDS). It utilizes clinical vignettes to measure quality of care. If a hospital passes a set quality of care index score, the payment for physicians is increased. Clinical vignettes focus on the management of 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: The claims processing procedure is still a manual operation. Electronic claims submissions have long been planned but have not been implemented. Hospitals or members fill out claims forms that are then submitted to PhilHealth within 90 days from hospital or health facility discharge. Two forms are usually submitted: First, a form that documents who the member is and premiums paid; and second, a form that details the service provided. Claims are submitted to 17 regional claims processing centers. These centers initially review if the claims are eligible. Review is inputted manually with a number of 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 have been planned but have not yet been implemented.
PhilHealth conducts its own monitoring and evaluation, though the law mandates that the University of the Philippines' National Institutes of Health also engages in monitoring of the scheme. Evaluations on the PhilHealth program are ongoing.
The Department of Health (to which PhilHealth is an attached agency) already conducts monitoring and analysis of various data, including number and value of claims filed, number of accredited providers, number and value of premiums paid, number of members, etc. There are attempts to expand beyond the above ‘traditional’ performance metrics and go deeper on each.
A group of USAID cooperating agencies has just completed one study (results not yet publicly released). The study looks at many aspects of the program, including financial risk protection, public awareness, coverage, benefit delivery ratio, and availability of providers.
There are reports that there are fraudulent claims against the state-health insurer. Losing P 4 billion. With these report it failed to prosecute erring doctors and hospital. AFP Medical Center, St. Luke’s 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 had been investigated for health insurance fraud.[11] 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 PhilHealth accredited patient.[12] In 2006 PhilHealth revove the accreditation of Sara Medical Clinic in Midsayap for ghost patients.[13]
In the pursuit of Philippine government to have universal health coverage for every Filipino. Starting from Philippine Medical Care Program in 1971. This was resulted to Philippine Medical Care Act of 1969.[14] As mandate the Philippine Medical Care Commission (PMCC) was created. Implemented in August 1971. In 1990 several bills passed that lead the significant improvement of the public health care insurance. The public insistent demand for broad affordable and comprehensive benefit. House Bill 14225 and Senate Bill 01738 enacted and became Republic Act 7875 also known as "The National Health Insurance Act of 1995". Approve by President Fidel V. Ramos on February 14, 1995. This become the basis of creation of Philippine Health Insurance Corporation.[15] On its 16 years anniversary theme " PhilHealth: Tapat na Serbisyo, Tapat na Benepisyo, Lahat Panalo".[16]