Anthony C.

Leachon, MD, FPCP, FACP

Independent Director
Representative of the Monetary Board
 Flow
1. Background
2. Goals of the meeting
3. Samples of risk management for common
reasons for reimbursement at PhilHealth
Fund Balance Projection
2012 YE Valuation

4
Fund Balance Projection
2013 YE Valuation

5
Fund Balance Projection
2014 YE Valuation

6
7
 Top 10 Causes of Mortality, Philippines 2010
Number Rate per
Cause of Death affected 100,000

1. Diseases of the Heart 102,936 109.5

2. Diseases of the Vascular System 68,553 72.9

3. Malignant Neoplasms 49,817 53.0

4. Pneumonia 45,591 48.5

5. Accidents 36,329 38.6

6. Tuberculosis, all forms 24,714 26.3

7. Chronic Lung Disease 22,877 24.3

8. Diabetes Mellitus 21,512 22.9

9. Nephritis/nephrotic syndrome/nephrosis 14,048 14.9

10. Perinatal disease 12,086 12.9

Philippine Health Statistics, 2010
 Benefit Payments
• Top conditions and procedures paid for by
PhilHealth in 2014
– Pneumonia - 7.6 Billion
– Hemodialysis - 4.6 Billion
– Cesarean delivery - 4.2 Billion
– Cataract removal - 2 Billion
– Maternity Care Package - 1.5 Billion

Source: Task Force Informatics

 Benefit Payments
• PhilHealth benefit payments have
substantially increased through the years
from P 12.9 billion in 2004 to more than P
78 billion in 2014.
• PhilHealth paid more than P 78 billion as
benefit payment in 2014, which is 41%
more than what was paid from the previous
year.
Source: 2014 PhilHealth Annual Report, PhilHealth Stats and Charts, 2007-2014
 Premium Collection
• PhilHealth premium collections have increased steadily
through the years from P 17.6 billion in 2004 to more than
P 81.4 billion in 2014.
• PhilHealth collected more than P 81.4 billion in 2014,
which is 43% more than what was collected from the
previous year.
• The increase was mainly due to the amount collected
from the national government as a result of the 14.7
million NHTS-PR families covered in 2014.
Source: 2014 PhilHealth Annual Report, PhilHealth Stats and Charts 2007-2015
 Annual Premium Collections vs.
Benefit Payments 2004-2014

Premium Collection
90. Benefit Payment 81.4
78.1

67.5
billion pesos

55.5
55.4
47.3
47.2
45.
34.9
34.8
30.5
29.1
24.7 25.6 26.24.3
23.1
22.5 17.6 18.7
17.5 17.1 17.4 18.2
12.9

0.
2004 2005 2006 2007 2008 2009
Year 2010 2011 2012 2013 2014
Source: 2014 PhilHealth Annual Report; PhilHealth Stats and Charts, 2007-
2014
 Goals of the Meeting
• Identify the risk
• Assess the risk
• Control risk
• Review the controls
• Create a blueprint for risk management
• Build a guiding coalition team
 PhilHealth Benefit Payments:

PhilHealth benefit payment is steadily increasing.

Claims reimbursement more than doubled in less than three
(3) years

And yet, the top conditions paid by PhilHealth does not

match priority health conditions and,

Out-of-pocket spending remains to be high

Source: 24 February 2016 Benefits Committee Meeting
 Pneumonia
2014 - P12.075 Billion
2015 - P 10.492 Billion

Policy statements released effective 15 September 2015. Among the conditions imposed were the
requirement of at least four (4) days confinement, three (3) days IV before shifting to oral antibiotics.

The policy statements were presented and approved by the Quality Assurance Committee (QAC) of
PhilHealth and eventually embodied in PhilHealth Board Resolution No. 1965.

Based on the latest stats, there has been a decrease in the number of cases paid by PhilHealth. For
HR CAP, 5,014 cases were paid in Oct 2015 and 3,691 in November 2015, down from 6,351 in
August before the effectivity of the circular. For MR CAP, 66,129 cases were paid in October 2015
and 52,288 in November 2015, down from 76,815 in August before the effectivity of the circular.
Note however that the November figures might not be complete yet because providers have 60 days
or until end of January to file the claim and hence, may still be in process.

The Philippine College of Chest Physicians (PCCP) in a letter dated Feb. 19, 2016 expressed
solidarity with PhilHealth as it seeks to have a meeting to discuss the current guidelines they are
updating or developing to “see how these can improve the coverage for these diseases”

Source: 24 February 2016 Benefits Committee Meeting

 UTI & AGE

UTI
2014 - P 1.810 Billion
2015 - P 1.960 Billion

Policy statements on the diagnosis and management of UTI released on 12 January

2016. The prescribed length of stay is minimum of 96 hours (4 days). The policy
statements were approved by the Quality Assurance Committee (QAC) in its meeting on
April 2015. In addition, the draft circular was likewise sent to the societies prior to
finalisation.
AGE
2014 - P 2.073 Billion
2015 - P 2.022 Biliion

Policy statements on the diagnosis and management released on 08 January 2016. the
prescribed length of stay is 72 hours (3 days). When it was being drafted, the policy
statements were sent to concerned societies for comments. Recent discussions indicate
that the LOS may be reduced to 48 hours.

Source: 24 February 2016 Benefits Committee Meeting

 Cataract

2014 - P 2.081 Billion

2015 - P 2.424 Billion

The guidelines on the diagnosis and management of cataract effective 15 August 2015
prescribed the maximum number of cataract pre-authorisations per surgeon at 10 a day
and 50 a month. Other conditions for quality care were emphasised in the circular like
rules on the bilateral procedures, post operative care and inclusion of IOL stickers in the
claims forms.

Source: 24 February 2016 Benefits Committee Meeting

 Hemodialysis

2014 - P 4.714 Billion

2015 - P 6.209 Billion

Starting 28 July 2015, the amount per session was decreased from P4,000 to P2,600 but
the maximum number of sessions was increased from 45 days to 90 days. The 90 days
is shared by the member and the dependents.

Thailand experience can give us an insight into possible courses of action. First, they
developed a program to address rising incidence of hypertension and diabetes and
secondly, they only admitted patients into HD upon certification of non-compatibility with
PD.

The current circular on HD provides the development of a Patient Registry. Once the
registry is in place, an option would be that new patients can only be admitted once such
certification of non-compatibility with PD can be secured. Supply constrains for solutions
would be a challenge that needs to be addressed.

Source: 24 February 2016 Benefits Committee Meeting

 Cardio Vascular

Stroke
2014 - P 2.630 Billion
2015 - P 2.788 Billion

Hypertensive
2014 - P 1.767 Billion
2015 - P 1.856 Billion

Source: 24 February 2016 Benefits Committee Meeting

 Deliveries
Obstetric Care
2014 - P 3.183 Billion
2015 - P 3.792 Billion

This includes the following: (1) Maternity Care Package (MCP) - P6,500 if delivered in
hospitals, P8,000 if delivered in birthing homes / lying in clinics, (2) Normal Spontaneous
Delivery (NSD) - P5,000 if delivered in hospitals, P6,500 if delivered in birthing homes / lying in
clinics, (3) Antenatal Care Package - P1,500, and (4) Newborn Care Package (NCP) - P1,750

This figure would have to disaggregated to separate actual deliveries from the services
intended for babies. At least one region has raised the alarm of the increasing number of sick
babies which may also drive utilisation of these claims.
Caesarian Deliveries
2014 - P 2.179 Billion
2015 - P 2.314 Biliion

Among the proposals being discussed are:

•Pre-authorisation from within the hospital prior to CS, if emergency, would need concurrence
of another physician
•If without pre-auth, would be paid at NSD rate
•Separate accreditation for CS

Source: 24 February 2016 Benefits Committee Meeting

 Recommendations on CS
1. Philhealth should develop an accreditation policy for
Cesarean Section(CS) that will be renewable every year.
Erring hospitals not accredited will not get any refund or
benefit from Philhealth.
(a) The hospital should provide Philhealth with updated
policies and guidelines on CS practices
(b) The hospital should have a CS committee that will audit
and monitor indications of cases
(c) Annual ocular visits by Philhealth should be done to check
if these policies are in place, assess the quality of the audit
and monitoring with proper documentation and system
of check and balance in place
(d) Annual Statistics should be included for re accreditation
Source: Cecilia L. Llave, M.D., PhD
 Recommendations
2. All elective CS will have a preoperative
notification with the approval of the Chairman
of the Department of OB Gyne as early as 5
months or 35 weeks that a CS will be done
and will have a pre operative approval by
Philhealth, included in the admission notes.
Source: Cecilia L. Llave, M.D., PhD
 Recommendations
3. For emergency CS, the attending physician should have an
additional approval from another consultant or his Chairman.

•These cases can be arranged to have a skype, text message,

phone call, immediate email notification of Philhealth that a CS will
be done on a patient and proper coding approval by Philhealth will
be issued and documented in the operative record.
•The problem is we need a focused person from Philhealth to do
this approval for 24 hours a day

4. Erring hospitals and doctors will be banned from the Philhealth

benefit.
Source: Cecilia L. Llave, M.D., PhD
 Summary
Strategies to Prevent PHIC Crisis

1.Increase the contributions – may be the best way

particularly in the employed sector (this is difficult given
the sin tax windfall)
2.Reduce expenses of PhilHealth, e.g., fraudulent
claims, abuse (wrong incentives)
3.Increase efficiency of collection (efficiency is low at 20
to 30%)- monthly gating and sales operations meeting
4.Reduce benefit coverage- Reassess the list and focus