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Enhancing PhilHealth Benefits Towards UHC February 13, 2012

A REFORMED, RESPONSIVE and RESTRUCTURED PhilHealth is how Dr. Eduardo P. Banzon, PhilHealth President and CEO envisions the organization to be. These are his clear and firm directives to provide better and improved social health insurance benefits and services to all Filipinos.

Reformed. The new payment scheme called case rates was introduced September 1 last year. This was initiated to empower members with the knowledge of how much PhilHealth covers for every medical condition. The Case Rate method of paying for benefits is similar to a "pakyaw" system wherein all services are already included in the package.

It was also designed to significantly reduce the turnaround time or processing of claim documents from 60 days to as quick as 10 days or even less since the benefit amount is clearly identified.

To date, PhilHealth has 23 medical and surgical procedures being paid for through the new payment scheme and with the new directions, expanded case rates will soon be implemented, making fee-for-service dispensable as what Banzon said in his previous interviews.

PhilHealth will also introduce to more hospitals Phase 1 of the e-claims Project that will do away with paper transactions, especially where claims processing is problematic. Through e-claims, accredited health care providers will be given access to PhilHealth’s database system that will enable them to automatically verify the benefit eligibility of members and their dependents.

Banzon is optimistic that once the e-claims Project is fully implemented, there will be a shift to paperless transactions from eligibility checking to claims filing. Indeed, this is a critical step towards improving the system and making things more convenient for PhilHealth members and partner-providers as well.

Responsive. The challenge of the Aquino administration has been explicitly communicated – to achieve Universal Health Care through the massive expansion of PhilHealth coverage to all Filipinos belonging to the marginalized sector of society. It started with the use of the National Household Targeting System for Poverty Reduction (NHTS-PR) of the Department of Social Welfare and Development (DSWD) to identify the poorest of the poor who will be provided with health insurance coverage. Universal Health Care, through PhilHealth, also aims to reduce out-of-pocket expenditures to prevent our poor kababayans from the burden of debt, especially in times of illness.

The introduction of the No Balance Billing Policy to Sponsored Program members is one of the more remarkable evidences that PhilHealth is sincere in its mandate of ensuring that all Filipinos will be provided with quality health care. “The marching orders coming from President Noynoy Aquino and Health Secretary Ike Ona are very clear, and we are doing all that is necessary, not only to make our benefits more responsive, but to ensure that our members will no longer spend a single centavo when they get hospitalized,” Banzon said.

He also emphasized that the NBB Policy will ensure that contracted hospitals and doctors would not charge more than the agreed case rate amounts.

The NBB that is currently being implemented in government hospitals will soon be offered to private hospitals. Eventually, it will be available to other member-types to enable them to experience true financial risk protection.

Restructured. PhilHealth is taking bold, aggressive moves to achieve UHC with the introduction of a new set of enhanced benefits designed to improve financial risk protection for all its members.

Priority goes to the roll-out of primary care benefits that will entitle members to basic, quality health care services through accredited public and even private health care providers nationwide. The primary care benefits will feature expanded outpatient providers in which every PhilHealth member will be assigned to facilities and primary care physicians. Implementation will be enhanced by introducing a system wherein release of payments is tied to performance, with incentives for additional quality and quantity indicators.

Also underway is the development of the PhilHealth Plus that will initially be available to government employees. These are supplementary benefits on top of the basic benefit package funded by either the employer or the members themselves. Similar to other benefits, The PhilHealth Plus is primarily designed to lessen out of pocket expenses.

Banzon assured members that no matter what it takes, these expanded benefits and improved quality services will be provided to all PhilHealth members."It is already a given that every reform requires adjustments. To make these reforms truly achievable, we should learn to accept its flaws, and from these flaws make the necessary transformation that will lead us to accomplishing our targets," he stressed.(END)

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