DR. NARISA J. SUGAY Senior Manager, Non Formal Sector Member Management Group THE CHALLENGES AND WAYS FORWARD IN PROVIDING UNIVERSAL HEALTH CARE

Transcription

1 DR. NARISA J. SUGAY Senior Manager, Non Formal Sector Member Management Group THE CHALLENGES AND WAYS FORWARD IN PROVIDING UNIVERSAL HEALTH CARE

2 Vision: Mission:

3 The challenge How to make health more inclusive?

4 No one should be left out Formal and informal sector workers are mandatory members. Lower income segments can be covered through cost-sharing scheme Poor and near-poor families are subsidized by the National Government.

5 the remaining 8% of the uncovered population is in the Informal Economy 2015 Projected Population: 101.4M Coverage as of December 2015 (CorPlan Data) 92% Sector Members Dependents Beneficiaries % Members in the Formal Economy 13,869,211 14,449,551 28,318,762 30% Members in the Informal Economy 3,424,526 5,033,910 8,458,436 9% Indigents 15,288,583 30,118,509 45,407,092 49% Sponsored Members 1,049,921 1,357,641 2,407,562 3% Senior Citizens 5,868,005 1,255,025 7,123,030 8% Lifetime Members 1,001, ,545 1,730,171 2% TOTAL 40,501,872 52,943,181 93,445, %

6 A Situation Analysis

7 Mechanisms to Cover the Workers in the Informal Economy

8 A. INDIGENT PROGRAM Legal Basis: 2016 GAA amounting to 37 Billion Pesos Target for CY 2016: Renewal of the M Listahanan/CCT/MCCT Families Enrolled in CY 2015 Workers in the Informal Economy who are included in the list of poor of the LISTAHANAN are automatically members of PhilHealth

9 B. SPONSORED PROGRAM The following are qualified to be enrolled and covered as sponsored members (Sec. 31, Rule VII): Orphans, abandoned and abused minors, out-of-school youths, street children, persons with disability (PWD), senior citizens and battered women under the care of the DSWD, or any of its accredited institutions run by NGOs or any nonprofit private organizations; Barangay health workers, nutrition scholars, barangay tanods, and other barangay workers and volunteers; Unenrolled women who are about to give birth; and Members in the informal economy from the lower income segment who do not qualify under the means test rules of the DSWD through a cost sharing mechanism with the sponsor/s and the member.

10 SPONSORED PROGRAM Point-Of-Care Enrollment Program MEMBERSHIP Identification of Hospital-Sponsored Members by Medical Social Workers Hospital to mandatorily enroll those classified as Class D and C3 Validity: First day of the month of confinement until December 31 of the same year Cost: Php2,400 for the current Calendar Year BENEFITS Immediate availment of members and hospital is entitled to reimbursement No Balance Billing Faster Turn Around Time of Claims Reimbursements

11 C. Informal Economy Program Who may be covered? (Section 5b of the IRR) Migrant Workers Informal Sector (workers) Self- Earning Individuals Filipinos With Dual Citizenship Naturalized Filipino Citizens Citizens of other countries Working and/or residing in the Philippines

12 Informal Economy Program Individually Paying Scheme Enrollment : Individual registration Premium rate: 2-tiered premium scheme Php 2,400/ annum (for those with monthly family income of Php 25,000 and below); Php 3,600/ annum (for those with monthly family income of above Php 25,000) Payment of premium: LHIO Initial; ACAs succeeding payment Eligibility: Contributions of 3/6 prior to the day of confinement Benefits: Inpatient Hospital Package and Regular Hospital Outpatient Services Requirements for availment: thru the portal

13 Informal Economy Program IPP- GROUP ENROLLMENT Partner organizations facilitates enrollment of members to PhilHealth and payment of premium contributions thru manual process. igroup PROGRAM Partner organized groups (OGs) facilitates coverage of members to PhilHealth using the egroup Web- Based Application System; OGs with at least 700 enrollees and committed to sustain the coverage for the entire year are entitled to premium discounts/ incentives.

14 Mandatory Coverage of Senior Citizens Republic Act All senior citizens shall be covered by the national health insurance program of PhilHealth. Funds necessary to ensure the enrollment of all senior citizens not currently covered by any existing category shall be sourced from the National Health Insurance Fund of PhilHealth from proceeds of Republic Act No , in accordance with the pertinent laws and regulations" Thus, RA provided coverage for FILIPINO SENIOR CITIZENS not currently covered by any membership program of the NHIP.

15 INFORMATION DRIVE AND RELATED INTERVENTIONS DISTRIBUTION AND ORIENTATION ACTIVITIES EXTENSION INFO ANGELS IHCPS thru PORTAL Conduct of ALAGA KA Program Conduct of FDS, LGU initiated orientations and other similar activities Upon hospitalization, online verification thru the HCP/CARES Portal

16 Role of the LGU s under RA10606

17 LGU Role as SHAPER of the NHIP Sponsor ROLE PARTICULAR Enrollment of the: Barangay workers and volunteers who are not members of the NHTS PR (eg. BHWs, BNS, Tanods etc.) Lowest segment of members in the informal economy thru cost sharing Critical poor thru Point-Of-Care (POC) - Women who are about to give birth

18 LGU Role as SHAPER of the NHIP ROLE Health Care Provider PARTICULAR Primary health care services, provision of PCB (enlistment and health profiling) of the indigents and sponsored enrollees Manage the Per Family Payment Rate (PFPR ) Hospital and other tertiary health care services with: No Balance Billing (NBB) for the poor and LGU enrollees IHCP Portal connectivity Assist PhilHealth CARES

19 LGU Role as SHAPER of the NHIP Advocate ROLE Particular Promote the NHIP and enjoin constituents to be enrolled to the Program Collaborate with DOH and DSWD on the establishment of Community Health Teams (CHTs) and Municipal Links (MLs), respectively Representation at the PhilHealth Board Payor Prompt and regular remittance of premiums of their employees and sponsored enrollees Option to become a PhilHealth Accredited Collecting Agent for PhilHealth premium contributions

20 LGU Role as SHAPER of the NHIP Employer ROLE Particular Ensure employees, including the job order contractors and service providers (security, janitorial, among others) access to PhilHealth benefits Regulator MANDATORY require all applicants of business permits to show proof of payment of PhilHealth premium contributions - Joint Memorandum Circular No. 001 dated May 9, 2014 of DILG, DTI, PhilHealth, SSS, Pag-ibig, Leauge of Cities of the Phils. (LCP) and Leauge of Municipalities of the Phils. (LMP)

21 Investment in HEALTH is always an investment towards PROGRESS

22 Thank you...

23 CASE RATE PAYMENTS Medical Cases Dengue I P8,000 Stroke (CVA-I) P28,000 Dengue II P16,000 Pulmonya I P15,000 Pulmonya II (high risk) Alta Presyon P9,000 Stroke na may Pagdurugo (CVA-II) Pagdudumi na may dehydration (AGE) P38,000 P6,000 P32,000 Asthma o Hika P9,000 Tipus o Typhoid Fever P14,000 23

24 CASE RATE PAYMENTS Surgical Procedures Outpatient Radiotherapy Outpatient Hemodialysis Panganganak ng Normal sa ospital at iba pang accredited na paanakan Panganganak ng Cesarean Section Pagtanggal ng Appendix P3,000 Raspa P11,000 P4,000 P6,500 (P8,000 sa L1) Pagtanggal ng Thyroid Pagsasa-ayos ng Luslos P31,000 P21,000 P19,000 Pagtanggal ng Suso P22,000 P24,000 Pagtanggal ng Matris P30,000 Pagtanggal ng Apdo P31,000 Cataract Surgery P16,000 24

25 CASE RATE PAYMENTS Outpatient Services NEWBORN CARE P1,750 P4,000 P600 P75,000 (non-health workers) P150,000 Health workers P3,000

26 Catastrophic o Z Benefit Packages Karamdaman/Operasyon Acute Lymphocytic Leukemia (ALL) sa mga bata na may standard risk Breast Cancer na nasa Stage 0 hanggang 3a pa lamang Prostate Cancer na may low hanggang intermediate risk Kidney transplant na may low risk Halaga ng Benepisyo P210,000 P100,000 P100,000 P600,000 Magagamit lamang sa mga piling levels 3 at 4 contracted hospitals na pag-aari ng pamahalaan 26

27 Additional Catastrophic o Z Benefit Packages Karamdaman/Operasyon Halaga ng Benepisyo Cervical Cancer with cobalt P120,000 Cervical Cancer with linear accelerator P175,000 Surgery for closure of ventricular septal defect P250,000 Surgery for total correction of tetralogy of fallot P320,000 Elective surgery for standard risk coronary artery bypass graft P550,000 Magagamit lamang sa mga piling levels 3 at 4 contracted hospitals na pag-aari ng pamahalaan 27

28 PRIMARY CARE PACKAGE Pangunahing serbisyo para makaiwas sa sakit Konsultasyon sa duktor Eksaminasyon ng kuwelyo ng matris para sa kanser Regular na pagkuha ng presyon ng dugo Edukasyon tungkol sa pagpapasuso ng sanggol Regular na pagsusuri ng suso Pagpapayo para sa malusog na pamumuhay Pagpapayo para sa pagtigil ng paninigarilyo Pagkuha ng taas, timbang at sukat ng baywang Pagsusuri ng prostate 28

29 PRIMARY CARE PACKAGE Mga pagsusuri para matukoy ang sakit Kumpletong pagsusuri ng dugo o complete blood count Pagsusuri ng ihi o urinalysis Pagsusuri ng dumi o fecalysis Pagsusuri ng plema o sputum microscopy Pagsukat ng asukal sadugo o fasting blood sugar Pagsukat ng kolesterol sa dugo o lipid profile Chest X-ray 29

30 PRIMARY CARE PACKAGE Gamot at medisina para sa piling karamdaman Hika o asthma kasama ang nebulisasyon Pagtatae o acute gastroenteritis na may bahagya o walang pagkaubos ng tubig sa katawan Ubo, sipon (Upper Respiratory Tract Infection)/Pulmonya na minimal o low risk Impeksyon sa daluyan ng ihi o Urinary Tract Infection (UTI) 30

31 igroup Program Features IPP-Group Enrollment Letter of Intent, Certificate of Good Standing with affiliated Institutions (SEC, LGU) and Group Policy Contract igroup partner facilitates the enrollment thru the egroup System Documentary requirements for affiliation with PhilHealth Registration 30 OG members Minimum Membership Required None Quarterly, Semi-Annual & Annual premium discount rate ranging from 4%- 9.7% (Only for OGs with members of 700 and above) Mode of Payment/ Remittance Premium Discount Rate MOA (optional) Group partner facilitates enrollment thru manual submission of list enrollees Quarterly, Semi-Annual, and Annual Electronic via e-group Billing and Submission of Report Manual billing and reporting In-patient & hospital outpatient benefits, & Primary Care Benefits, Comparison of Group Enrollment Schemes Automatic Availment within the validity period Benefit Package and Availment of benefit Eligibility None Inpatient & hospital outpatient benefits. 3 mos. qualifying contribution within the 6 mos. Period prior to the day of confinement