Providing Health Insurance for the Poor: The Philippine Experience. Leizel P Lagrada MD MPH PhD Berlin Global Learning Forum/ June 23-27, 2015

Transcription

1 Providing Health Insurance for the Poor: The Philippine Experience Leizel P Lagrada MD MPH PhD Berlin Global Learning Forum/ June 23-27, 2015

2 Experience of Enrolling the Poor in selected JLN countries Population Coverage Technical Initiative Workshop; Manila, December 2014 JLN countries shared experiences in reaching disadvantaged populations to achieve UHC

3 Kenya Challenges Enrollment is compulsory for formal sector, but voluntary for all other groups. Lack of incentive for the poor, near poor and informal groups to enroll Strategies Innovative partnerships between NHIF and mobile network providers to collect premiums via mobile money National Registration bureau to require membership to renew work permits and licenses

4 Ghana Challenges Corruption leads to errors of inclusion in targeting; insurance agents sometimes enroll new members incorrectly as indigent to offer them premium exemption Strategies Use of biometric technology to properly identify the enrolled indigents

5 Vietnam Challenges Corruption leads to errors of inclusion in targeting; incorrect identification of individuals as poor to provide them with benefits and premium exemption Strategies Individuals identified as poor have their names placed on a list, which is published in a public area (reduces the risk of leakages)

6 National Health Insurance Program expansion through the years.. Expanding SHI from employed sector to informal sector Consolidating the health insurance programs for private employees, civil servants and overseas workers into one SHI Shifting from counterpart contribution scheme between the NG and LGUs to full NG contribution to enroll the poor. Single mechanism to identify the poor, using the NHTS-PR list generated by DSWD Earmarked sin taxes to support UHC, including the premium for the poor

7 Characteristics of the National Health Insurance Program Mandate Coverage Provide all citizens with the mechanism to gain financial access to health services RA 7875 (1995) as amended by RA 9241(2004) & RA (2013) Compulsory coverage for all citizens; Family-based membership where primary member and qualified dependents have almost the same benefit Administration Single-payer system Financing For employed: Payroll-based premium with employer and employee contributions (2.5% of basic salary) For Self-employed: Two-tiered annual premium PhP2,400 (US$54) with less than P25,000 (US$563.5) monthly income) PhP3,600 (US$81) for those earning P25,000 or higher monthly income Government subsidy for the poor and senior citizen (PhP2,400 annual premium)

8 Characteristics of the National Health Insurance Program Benefits Uniform in-patient package,including catastrophic benefit packages Primary care benefit for the indigents and other sponsored members (will also be rolled out to all members ) Providers Voluntary accreditation of government and private health facilities Plus: contract with hospitals to deliver catastrophic benefit packages Payment Mechanism Case rate for in-patient benefits Special Case Rate for Z packages Per Family Payment Rate (PFPR) for Primary Care Benefit (Tsekap) Privileges Automatic coverage of the poor assessed by NHTS-PR of the Department of Social Welfare and Development (DSWD) No Balance Billing for indigents and sponsored members when admitted in government hospitals Automatic availment of benefits by pregnant women and those enrolled as sponsored member at point-of-care Lifetime entitlement to senior citizens (60 years old and above)

9 Where are we right now? 17 REGIONAL O F F I C E S 106 L O C A L OFFICES 6,400 OFFICERS S T A F F F I L I P I N O S ~100,000,000

10 NHTS-PR: Targeting the Poor under NHIP Individuals who have no visible means of income, or whose income is insufficient for family subsistence are identified by DSWD as poor Based on specific criteria set for the purpose of National Household Targeting System for Poverty Reduction (NHTS-PR) Once identified through NHTS-PR, poor families are automatically covered by the National Health Insurance Program

11 NHTS-PR: The Process 1) Geographic Targeting Enumeration strategy was defined using poverty maps Poorest municipalities were covered first and all households were assessed Less poor municipalities had combination of enumeration of pockets of poverty and on demand applications 2) Household Assessment Households were assessed through home interviews to gather information on Household Assessment Form (HAF) Supervision was randomly done during the field work to ensure good quality of information Processing was done online at regional offices with validation routines to check the quality of data PMT scoring was applied to PMT ready data 3) Validation List of poor household selected through PMT as those below provincial poverty thresholds was published at the village level Addressing complaints about exclusion and inclusion Verification of data, gathering of evidence, assessing the excluded Providing evidence for Local Verification Committee for final decision Processing of validated data Reference: Fernandez, L. Design and Implementation Features of the National household Targeting System in the Philippines, Philippine Social Protection Note No. 5. WB and AusAID, June 2012

12 What about those who were missed? Enrollment at Point of Care 1. Non-member/ beneficiary patients, who are assessed and classified as Class C-3 or D by the Hospital Medical Social Welfare Officer (HMSWO)* 2. Member/beneficiary patients who are not covered due to lack of qualifying contribution and classified to be Class C-3 or D by the HMSWO Note: * DOH Administrative Order No. 51 s- 2001Classification of Admitted Patients

13 Member Enrollment Made Simple: The new PMRF is enough No more documentary Requirements! A person intending to enroll as member (including dependents) shall submit a properly accomplished PhilHealth Member Registration Form

14 Population coverage in millions Use of NHTS-PR to cover the poor Population with PhilHealth Coverage between Overseas Workers Lifetime Employed- Private Employed- Government IPP Sponsored Program.and to extend coverage to near poor

15 Who does what in providing coverage for the poor? DSWD Manages NHTS-PR Processes on-demand application Shares list of poor household to PhilHealth PhilHealth DOH DOF/DBM LGUs/public hospitals other sponsoring agents Matches DSWD list with PhilHealth membership base Identifies primary members/families from NHTS list Provides coverage for identified indigent and poor families Seek adequate budget to enroll the NHTS list of families Monitor health care utilization of indigent families Invest in health facilities and services used by the poor Raises revenues from sin taxes to enroll the poor and invest in public health facilities Point of care enrollment Facilitate enrollment of near poor/ informal sector

16 Cooperative work within PhilHealth.. Central Office Regional Offices Local health insurance office PhilHealth outlets Member Data Management Health Benefits and Access to Services Member Empower ment Effective Coverage for the Poor

17 Challenges & Opportunities.. Mandatory membership for all Filipinos Sustain Membership Coverage How to cover the uninsured workers in Informal Economy Enforcement and compliance of Employers and members of the NHIP Law Empowered Members Knowing the benefits and how to avail the benefits Strengthen Partnership with Stakeholders

18 Perspectives for future Guarantee full financial risk protection for the poor through No Balance Billing policy Protect the non-poor from impoverishing effect of health care cost through fixed co-pay Monitor and measure the financial risk protection and health care utilization (health outcomes) provided by the NHIP and use the evidence to further improve the program

19 Thank you.