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PhilHealth Sets Benefit Ceilings for Leading Medical and Surgical ProceduresFebruary 17, 2011

The Philippine Health Insurance Corporation (PhilHealth) is poised to launch on the first half of the year a standardized set of reimbursement for 22 common medical and surgical cases being availed of by its members in accredited hospitals nationwide.

This was disclosed recently by Dr. Rey B. Aquino, PhilHealth President and CEO, as the state-run health insurance firm is making the final stretch of its preparation before these are formally rolled out to the public. "We are just making some fine tuning so that the next big wave of benefit adjustments on the second quarter of this year will be welcomed by our members and health care providers with great anticipation" Aquino said during their 16th anniversary press briefing in Mandaluyong City.

PhilHealth is currently spearheading the nationwide observance of February as National Health Insurance Month and its 16th founding anniversary last Monday.

Among the 11 medical cases that will soon be paid on a case rate basis are dengue 1 and 2, pneumonia 1 and 2, essential hypertension, cerebral infarction and hemorrhage, acute gastroenteritis, asthma, typhoid fever, and newborn care package; while surgical cases include radiotherapy, dialysis, normal deliveries and deliveries by caesarian section, appendectomy, cholecystectomy, hysterectomy, dilatation and curettage, thyroidectomy, herniorrhapy and mastectomy.

As soon as these are introduced, these will be reimbursed on a case-rate basis, a payment method that reimburses hospitals a pre-determined fixed rate for each treated case.

The system is a departure from the usual "fee-for-service" method where providers are paid for each unit of service, over which there is a tendency for abuse because expenditures tend to increase if more services than what is needed are provided or more expensive services are substituted for less expensive ones.

Aquino said that they are moving towards this kind of system to help ensure better health outcomes, fair health financing, and equitable access to health care especially to the disadvantaged sectors. To do this, they are looking into a possibility of a "no balance billing policy" for its Sponsored Members, while setting fixed co-payment rates for the rest of its members admitted in hospital bed accommodations purposely identified for the said reimbursement set up.

With the case-rate payment, PhilHealth expressed optimism that it will significantly reduce high out-of-pocket payments by its members, and gives the member a clear idea of the benefits that they will be able to avail of, while some 1,600 accredited health care providers taking part in this new development are saved from the normally tedious administrative work for their reimbursements.

It can be recalled that PhilHealth already adopted the case rate system in its maternity care package for normal spontaneous delivery, newborn care benefit package, outpatient HIV/AIDS package, and outpatient malaria package.

Furthermore, Aquino said that the choice of diagnoses listed under the new case rates was based on PhilHealth's claims payment monitor in 2010 where the 22 cases up for case rate payment this year represent almost half of its total benefit claim payments last year. "We expect that the move will indeed be more meaningful as it will address the topmost benefit availments for the coming years" he concluded. END

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