(NAR) VOL. 24 NO. 4 / OCTOBER - DECEMBER 2013
(b) |
Universality that
states that “the National Health Insurance Program shall give the
highest priority to achieving coverage for the entire population with at
least a basic minimum package of health insurance benefits.” |
(c) |
Equity that emphasizes that “the Program shall provide for UNIFORM BASIC BENEFITS (emphasis supplied).” |
(f) |
Effectiveness that stipulates that “the Program shall balance economical use of resources with quality of care,” |
(m) |
Cost Sharing that mentions that
“the Program shall continuously evaluate its cost sharing schedule to
ensure that costs borne by the members are fair and EQUITABLE and that
the charges by health care providers are reasonable,” and |
(q) |
Cost Containment that stresses
that “the Program shall incorporate features of cost containment in its
design and operations and provide a viable means of helping the people
pay for health care services.” |
The adoption of the Fee-for-Service (FFS) Provider Payment Mechanism has intrinsic constraints that limited the Corporation from fully realizing the intents of the aforementioned guiding principles. Globally, studies have shown how FFS has led to prolonged hospital stays, overutilization of diagnostic procedures, and provision of unnecessary and inefficient health care services that insurances paid for without offering any additional value to members. These wasteful payments significantly reduced the already constricted financial and administrative resources of the Corporation. Moreover, though the FFS schedule is uniform across member categories, there is inequity in terms of claims paid for similar conditions when comparing payments to private and government health care institutions (HCIs). For a similar condition, PhilHealth beneficiaries may receive higher reimbursements if they go to private than government HCI. However, despite higher payments, Phil Health’s support value in private HCIs remains lower than 30% as an average. Worse, indigent patient members still have to pay cost-shares for services even in government HCls whereby failure to produce the needed finances from their own pocket limits their access to quality health care services.
On the other hand, the global trend towards the achievement of Universal Health Care (UHC), locally embodied in the Kalusugan Pangkalahatan (KP) Program, is to have social health insurances (PhilHealth) shift to and implement Case-based Payments as Provider Payment Mechanism. Case-rated payments and the more advanced Diagnosis-Related Group (DRG) Payments are advantageous to the members and health care providers alike. These serve to have one uniform rate for the provision of a minimum level of quality care under the most modest of accommodations regardless of member category or the nature of the health care institution. Thus, it promotes an equitable basic standard benefit that is the same for similar conditions whether admitted in government or private HCIs. By having fixed amounts, Case Rate (CR) also allows PhilHealth to improve administrative efficiency and reduce turnaround time for paying health care providers. Case rate allows PhilHealth members to know how much they are entitled to in terms of benefit payments thereby strengthening their own power as a patient of said health care institution and member of the Corporation. It reduces the discretion of claims processors in terms of deductions and computation of reimbursements. It allows PhilHealth to effectively impose the No Balance Billing (NBB) policy for sponsored program members admitted in ward or ward-type accommodations in government health care institutions. The latter is a policy intended to assure financial protection for the poor and indigent members in order for the country to collectively enjoy the advantages and societal benefits of a healthier community.
Therefore, the mounting evidences of the advantages of paying case rates require PHilHealth to implement an all case rates at the soonest possible time. The initial experiences of Case Rates, implemented thru PhilHealth Circular 11 s. 2011, have proven its value. The NBB policy for sponsored program members admitted in government hospital wards was introduced for the initial 23 conditions under the Case Rates system. Turnaround time (TAT) for claims processing improved from more than 70 days before health care providers received their payments to 45-55 days with some regions reporting TATs of 17 days.
However, the fact that case rates were limited to only 23 conditions out of the vast number of possible procedures and medical conditions has strained the PhilHealth operational systems and has stymied the realization of the promises of case rates. In response to this, the PhilHealth Board through Board Resolution No. 1679 s. 2012 has approved the shift of the provider payment mechanism from FFS to Case Rates. In response to the Board directive, extensive consultations on the concepts of case based payments, the goals and intents of CR, the coverage of the NBB policy, and the determination of the rates were conducted with various stakeholders nationwide. For consistency, herein follows the policy statements and reforms devised to guide the implementation of case rates.
II. GENERAL OBJECTIVES
III. SCOPE AND COVERAGE
IV. DEFINITION OF TERMS
V. GENERAL POLICIES ON CASE RATE PAYMENTS
VI. MEMBER BENEFITS UNDER CASE RATES
VII. SYSTEM ENHANCEMENT
The PhilHealth database shall be designed and improved to be able to generate real time, quality and responsive information/ evidences to be used in the development of evidence-based policies and rates adjustments.
VIII. COMPLIANCE MONITORING
Compliance of health care providers to the policy contained herein shall be regularly monitored and evaluated. Post-audit evaluation shall also be conducted on CR claims subject to the rules of existing post-audit implementing guidelines.
IX. PERIODIC REVIEW, EVALUATION AND ADJUSTMENTS IN POLICY AND RATES
This Circular on case rates shall be reviewed annually and as necessary.
Costing spreadsheets, actual costs, proposed costing and grouping from medical societies and organizations, costing surveys conducted by the Corporation and other groups, monitoring results, feedback from patients, members, partners and providers, among others, shall be used to enhance the rates and groupings for the case rates.
X. PENALTIES AND SANCTIONS
Any violation of the provisions of this Circular shall be meted the appropriate penalty and sanctions pursuant to R.A 7875, as amended by R.A. 10606, its IRR and applicable issuances of PhilHealth.
In addition, any violation of the health care providers shall be included in the monitoring and evaluation of health care providers' performance under the Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS). The penalties to these violations shall be charged to future claims of the HCI.
The Department of Health (DOH), the Professional Regulations Commission (PRC), and/or other concerned agencies shall be furnished with a copy of the decision rendered against the HCl for information and/or appropriate action.
XI. REPEALING CLAUSE
All provisions of previous issuances that are inconsistent with any provisions of this Circular are hereby amended/ modified/or repealed accordingly.
XII. SEPARABILITY CLAUSE
In the event that a part or provision of this Circular is declared unauthorized or rendered invalid by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective.
XIII. EFFECTIVITY
This Circular shall take effect fifteen (15) days after publication in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.
(SGD) ALEXANDER A. PADILLA
President and CEO