Universal Health Care-Students

Universal Health Care:
“What You Should Know”
JANICE D. DE LEON, MD, DFM, FPAFP, FPSP, MA(c)

MCU- COM
CHAIR. DEPT. OF FCM
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 ENTITLEMENT TO BENEFITS
 HEALTH SERVICE DELIVERY
 DRGs
 FUNDS
 OFFENSES
INTRODUCTION
SDG
INTRODUCTION
 Republic Act No. 11223

 Enacted by President
Rodrigo Roa Duterte last
Feb. 20, 2019
 IRR was signed by Health
Sec. Francisco Duque III
last October 10, 2019
Universal Health Care
Kalusugang Pangkalahatan
“ provision to every Filipino of the highest
Possible quality of healthcare that is accessible, efficient,
Equitable distributed, adequately funded, fairly financed,
And appropriately used by an
Informed and empowered public”
Universal Health Care
Kalusugang Pangkalahatan
 give priority to the poorest of the poor Filipino
families with a monthly income of Php 7,300 or
below
Partners with government poverty alleviation
programs
National Household targeting System for Poverty
Conditional Cash Transfers for Pantawid
Pamilyang Pilipino Program (4Ps)
Universal Health Care 3 Thrusts
1. Financial risk protection through expansion in

enrollment and benefit delivery of the National
Health Insurance Program
2. Improved access to quality hospitals and
health care facilities
3. Attainment of health-related SDGs
INTRODUCTION
 Principles:
 Integrated and comprehensive approach to health
literacy, provision of healthy living conditions and
protection from hazards and risks affecting health
 Provides access to a comprehensive set of quality and
cost-effective health services, with priority to the
population who cannot afford such services
 Whole-of-system, whole-of-government and whole-of-
society approach in developing, implementing, monitoring
and evaluating health policies and programs
 People-oriented approach centered on people’s needs
and well-being
-Universal Health Care Act, Implementing Rules and Regulations, Oct. 2019
INTRODUCTION
 GENERAL OBJECTIVE:
 Progressively realize universal health care in the country
through a systemic approach and clear delineation of
roles of key agencies and stakeholders towards better
performance in the health system; and
 Ensure that all Filipinos are guaranteed equitable access to
quality and affordable health care goods and services
and protected against financial risk.
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
UNIVERSAL HEALTH CARE
COVERAGE
 Every Filipino citizen will be automatically included in the
NHIP
 Immediate eligibility and access to preventive,
promotive, curative, rehabilitative and palliative care for
medical, dental, mental and emergency health services
 Within 2 years, PhilHealth shall implement a
comprehensive outpatient benefit ( services of
healthcare professionals, diagnostic, laboratory, dental,
personal preventive services, prescription drugs and
biologicals)
COVERAGE
COVERAGE
 Every Filipino shall register with a public or private
primary care provider (navigator, initial and continuing
point of contact) of choice with due consideration to:
 Proximity and ease of travel
 Absorptive capacity of the provider
 LGUs shall register their respective constituents to a primary
care provider
 DOH shall issue guidelines for the licensing of the primary
care providers.
COVERAGE
 Primary care providers will deliver free essential health services
and will guide patients through the different health care
facilities.
 One medical doctor per 20,000 population; 1 nurse per 10,000
population; and 1 midwife per 5,000 population. Data from
DOH show that 28% of provinces have attained the 1
MD/20,000 population, 99% have reached the 1 N/10,000
population, and 79% have achieved the 1 MW/5000
population
 NEDA, 2019
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
MEMBERSHIP- CONTRIBUTORS
 2 types
 Indirect
 Direct
 employees with formal  Indigents
employment  4Ps beneficiaries
 kasambahays  senior citizens
 self-earning individuals  persons with disability
 professional practitioners  21 and above without the
 OFWs capacity to pay (to be
determined by the DSWD)
 Filipinos living abroad
 SK officials
 Filipinos with dual citizenship
 lifetime members and
 all Filipinos above 21 with
the capacity to pay
MEMBERSHIP
 DEPENDENTS:
 Legal spouse who is not an active member
 Unmarried and unemployed legitimate, illegitimate, legally
adopted and step children below 21
 Foster child
 Parents above 60 not otherwise an enrolled member
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
ENTITLEMENT TO BENEFITS
 Immediate eligibility without the need to present PhilHealth ID

 Those who are not in the PhilHealth database shall be duly
registered by health care facilities
 Failure to pay premiums shall not prevent enjoyment of the
benefits, direct contributors shall be required to pay all missed
contributions, with interest compounded monthly:
 3% for employers
 1.5% for self paid individuals
-Usec. Maria C. Villaverde, DOH

Primary Care Benefits (PCBI) or
“TSeKaP”
 Primary Preventive Services
 Consultation of establishment and updating individual health profile
 Visual inspection with acetic acid
 Regular BP measurements
 Breastfeeding program education
 Periodic clinical breast examination
 Counselling for lifestyle modification
 Counselling for smoking cessation
 Body measurements
 Digital rectal examination
 Oral check-up and prophylaxis(12 yrs and below)
“TSeKaP”
 Diagnostic Examinations
 CBC
 Urinalysis
 Fecalysis
 Sputum Microscopy
 Lipid Profile
 FBS
 Creatinine
 ECG
 Chest x-ray
“TSeKaP”
 Capitation Payment: Per Family Payment Rate (PFPR)
 Php 1,800.00 cost per family
 800
 Maximum services and diagnostics
 400 – for TseKaP services
 400 – complete family profile
 200 – if incomplete
 1000
 Maximum for medicines
 PREMIUM CONTRIBUTIONS: DIRECT CONTRIBUTORS

YEAR PREMIUM RATE INCOME FLOOR INCOME CEILING
2019 2.75 % Php 10,000.00 Php 50,000.00
2020 3.00 % Php 10,000.00 Php 60,000.00
2021 3.50 % Php 10,000.00 Php 70,000.00
2022 4.00 % Php 10,000.00 Php 80,000.00
2023 4.50 % Php 10,000.00 Php 90,000.00
2024 5.00 % Php 10,000.00 Php 100,000.00
2025 5.00 % Php 10,000.00 Php 100,000.00
 SPECIAL PROVISIONS:
 Self earning individuals and practicing professionals
Computed based on the individual’s monthly income. Non-
submission of acceptable proof of actual income shall result
in the charging of the rate based on the income ceiling
 Kasambahays
 OFWs
 Persons with disability
Sample Computation:
Self-Paying Individuals
YEAR Percentage Income Amount to be Total for the

Ceiling paid per year
month
2020 3.00 % Php 60,000.00 Php 1,800.00 Php 21,600.00
2021 3.50 % Php 70,000.00 Php 2,450.00 Php 29,400.00
2022 4.00 % Php 80,000.00 Php 3,200.00 Php 38,400.00
Total amount to be paid for 3 years Php 89,400.00

 Kasambahays
Shouldered by the employer
>Php 5,000.00/month, the kasambahay shall pay the
proportionate share in the premium
 OFWs
 Kasambahays
 OFWs
Salary-based
With acceptable proof of actual income
 Kasambahays
 OFWs
Formally employed
Shared equally by the employers and the national
government
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
HEALTH SERVICE DELIVERY
-PhilHealth
Minimum Population-Based health
Service Components:
Primary care Provider
Epidemiological Surveillance Systems
Proactive, effective and evidence-based
health promotion programs
Timely, effective and efficient
preparedness and response to public
health promotion program and disasters
BED CAPACITY
 Bed Capacity of hospitals:

 Government general hospitals
Annually submit an online reporting system on the allotment and
actual utilization of the authorized beds for basic or ward
accommodation
90 % of the bed capacity
 Specialty hospitals
70 %
 Private hospitals
10%
DOH shall provide an

updated list of public
and private apex or
end referral hospitals
within every last
quarter of every year

 Primary Care Provider
Network
 Public, private or mixed
primary care providers
 Initial contact and
navigator
 Coordinate patients to 2-
way referrals
 Provide patients records
accessible throughout the
health system
 Implement public health
programs
 Minimum population-based
health service components:
 Primary care provider
network
 Epidemiologic surveillance
systems
 Health promotion
programs
 Preparedness and
response to public health
emergencies and disasters
 DOH shall finance
population-based health
services
 Health care provider:
 Health facility (public or private), devoted primarily to the
provision of services, or in need of obstetrical or other
medical and nursing care
 Health care professional (doctor of medicine, nurse,
midwife, dentist or other allied professional or practitioner
duly licensed to practice)
 Community-based health care organization
 Pharmacies or drug outlets
 Laboratories and diagnostic clinics
 Primary care provider:
 PRC: regulate the number of
trainees per program
 Residents of underserved and
unserved will be prioritized for
scholarship programs – with return
service for at least 3 full years
 Register medical and allied health
professionals and location of
practice
 Reorient health care professional
and health care worker curriculum
towards primary care
 Health care provider network(HCPN)
 Primary to tertiary care providers, public or private , offering
people-centered and comprehensive care, with the primary
care provider acting as the navigator and coordinator within the
network
 Primary care provider – with certification in primary care given
by DOH
Primary care practice- multidisciplinary team of health workers
Primary care facility – licensed by DOH that delivers primary care
services
Primary care worker – health care worker
(professional/volunteer) certified by DOH
 NETWORK CONTRACTING:
 Primary care provider
linked to secondary and
/or tertiary care providers
 Patient navigation and
coordination system
 Electronic health records
 Licensed and accredited
by DOH

 INDIVIDUAL-BASED HEALTH SERVICES
 1 recipient
 Limited effect at a population level
 Does not alter the underlying cause
of illness
 Services:
 Ambulatory care
 Inpatient care
 Medicine
 Laboratory tests
 Procedures
 NETWORK CONTRACTING:
 Individual-based Health Services
 Conditions:
 Members’ access shall not be
compromised
 Agree to service quality, co-
payments/co-insurance, and data
submission standards
 PhilHealth and DOH shall
incentivize health care providers
 Apex or end-referral hospitals
maybe contracted as stand-alone
health care providers by
PhilHealth
 Individual-based Health
Services
 PhilHealth will finance using
capitation and case rate
payments
 Contracted networks and
apex hospitals will be paid
using the DRGs
OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
Diagnosis Related Groupings/Case Mix
System
 Case mix system
 Classification of patient treatment episodes designed to
create classes which are relatively homogenous in respect
of the resources used and which contain patients with
similar clinical characteristics
- Workshop on DRGs, PHAPi, Feb, 24, 2020

System
- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

System

System

System
 2 main components
 Disease classification
Coding for Diagnosis (ICD-10)
Coding for Procedures (ICD- 9 CM/ ICHI- International
Classification of Health Interventions)
 Cost Analysis
Top-down costing
Activity-based costing
Clinical Pathways

System

System

System

System
 UNU-CBG SOFTWARE
 Universal and Unified Case-Based
Groups Grouper Software
 1,077 cases
 Uses 5 digit-system (e.g. A-1-23-1)
 3 levels of severity
 CCM
 Clinical costing modeling software
* Access to Case mix Online Training
Programme :
http://online.casemix.com.my/

System

System

System

System

OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES

OBJECTIVES
 INTRODUCTION
 COVERAGE
 MEMBERSHIP
 DRGs
 FUNDS
 OFFENSES
OFFENSES
 INDIVIDUAL-BASED HEALTH SERVICES
 Classification:
 Fraudulent
 Unethical
 Abuse of authority
 Penalties:
 Php 200,000.00 for each count, or suspension of contract
up to 3 months or both
OFFENSES
 Criminal Case
 Violation of RA 7875 and RA 11223
 Imprisonment of 6 months and 1 day up to 6 years
OFFENSES
 Offenses of Members
 Any violation of the act
 Pay all missed contributions with interest
 Cooperates or agrees to the commission of violation of a
contracted health care provider or employer
 Php 50,000.00 for each count or suspension from availment
for not less than 3 months but not more than 6 months
OFFENSES
 Offenses of Employers
 Fails or refuse to register employees
 Fails to deduct contributions
 Failure to remit contributions
 Failure to submit report
 Php 50,000.00 for every violation/employee, or
imprisonment of not less than 6 months but not more than
1 year
OFFENSES
 Other violations:
 Failure to submit health and health-related data to
PhilHealth
 Not less than Php 5,000.00 but not more than Php 20,000.00
per count
TRANSITORY PROVISION
 PHASE I
 Preparatory works needed to facilitate local health systems
 PHASE II
 DOH provision of technical assistance to the province-wide and
city-wide health system
 Health care provider networks shall be contracted by PhilHealth
 PHASE III
 Monitoring of the functionality of the integrated local health
system
Universal Health Care:
“What you should know”
 IRR was signed last Oct. 10, 2019
 Will be implemented by 2023
 All Filipinos are already eligible for Philhealth benefits
 Employed OBs contribution will be shared with employers, private-
practicing OBs will pay contribution according to income
 Should have a network with a Primary Care Physician
 Included in the Individual-Based Health Services/Apex hospitals
 Diagnosis will be based on ICD 11/procedures based on ICD 9-CM or
IHCI
 Payments will be based on tariffs computed by the PhilHealth
 BE AWARE of the offenses and penalties

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Universal Health Care:

“What You Should Know”

JANICE D. DE LEON, MD, DFM, FPAFP, FPSP, MA(c)

 Republic Act No. 11223

1. Financial risk protection through expansion in

 Immediate eligibility without the need to present PhilHealth ID

-Usec. Maria C. Villaverde, DOH

 PREMIUM CONTRIBUTIONS: DIRECT CONTRIBUTORS

YEAR Percentage Income Amount to be Total for the

2020 3.00 % Php 60,000.00 Php 1,800.00 Php 21,600.00

2021 3.50 % Php 70,000.00 Php 2,450.00 Php 29,400.00

2022 4.00 % Php 80,000.00 Php 3,200.00 Php 38,400.00

Total amount to be paid for 3 years Php 89,400.00

 Bed Capacity of hospitals:

DOH shall provide an

-Usec. Maria C. Villaverde, DOH

-Usec. Maria C. Villaverde, DOH

- Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

- Prof. Syed Aljunid, Workshop on DRGs, PHAPi, Feb, 24, 2020

-Usec. Maria C. Villaverde, DOH

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