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Welcome to the Quality Assurance Committee Corner!

This corner aims to increase awareness of our stakeholders on the importance of quality in health care. This will also guide the accredited health care providers in the clinical management based on the applicable policy statements.

Through this corner, PhilHealth also aims to guide our medical evaluators and adjudicators when evaluating and/or adjudicating claims.

Brief Background

The Quality Assurance Committee (QAC) was created pursuant to PhilHealth Board Resolution No. 1109 s. 2008 that approved the consolidation of the functions of the Peer Review Committee (2002 - 2008) and the RVU Oversight Committee (1999 - 2008) into one committee. Provided by the law, as stated in the Revised IRR of the National Health Insurance Act of 2013 (RA 7875 as amended by RA 9241 and RA 10606) the establishment of a peer review will ascertain the quality of health care services and standards of care among health care providers.

Who are the members of QAC?

The QAC acts as the expert panel that assist PhilHealth in its quality assurance activities such as development of policies, use of clinical practice guidelines/acceptable standards of quality care, resolution of clinical and non-clinical issues, application of information systems/adoption of tools and performance monitoring of accredited health care providers (HCPs) among others.

The conduct of QAC meeting to deliberate and resolved health-related issues was adopted in the Health Care Provider Performance Assessment System (HCPPAS) for the monitoring of performance among HCPs. During committee meetings, the representatives from the member specialty societies discuss complicated claims referred by the regional offices particularly with complaints against HCPs or clarification of health management if warranted by quality of care. The resolutions of cases are based on best available evidence and expertise in medicine. PhilHealth translates these resolutions into policy statements as applicable.

  PhilHealth Committee designation
1 Senior Vice President – Health Finance Policy Sector Chairperson
2 Vice President – Quality Assurance Group Vice Chairperson
3 Senior Manager – Standards and Monitoring Department Member
4 Senior Manager – Accreditation Department Member
5 Senior Manager – Benefits Development and Research Department Member
6 Senior Manager – Fact-finding Investigation Enforcement Department Member
External organization Member’s link
7 Representative/alternate – Philippine Medical Association www.philippinemedicalassociation.org
8 Representative/alternate – Philippine College of Physicians pcp.org.ph
9 Representative/alternate – Philippine Society of Anesthesiologists psa.org.ph
10 Representative/alternate – Philippine College of Surgeons www.pcs.org.ph
11 Representative/alternate – Philippine Academy of Ophthalmology pao.org.ph
12 Representative/alternate – Philippine Academy of Family Physicians thepafp.org
13 Representative/alternate – Philippine Obstetrical and Gynecological Society pogsinc.org
14 Representative/alternate – Philippine Pediatric Society pps.org.ph
15 Representative/alternate – Philippine Hospital Association philhospitalassn.org
16 Representative/alternate – Board of Medicine, Professional Regulation Commission www.prc.gov.ph/medicine

Policy Statements

Policy statements are set of minimum expectations pertaining to quality of care, based on current available evidence.

In the development of policy statements, the following are considered:

• Current standard or preferred practices in healthcare (e.g. practice guidelines)
• Relevant law, rules, or policies (e.g., PNF, ARSP)
• Specific reimbursement policies (e.g., once in a lifetime procedure, laterality, number of sessions)

It is important to emphasize that Policy Statements (on quality care) do not intend to duplicate nor replace clinical practice guidelines but supports them as the recommendations with strong evidence are adopted in the document to ensure standard of practices are provided to all Filipinos under the care of PhilHealth-accredited health providers.

Policy Statements may be updated every 2-3 following publication of updated CPGs.

As to date, listed below are the published policy statements through a PhilHealth Circular that were approved by the QAC:

• Indications for Cord Coil
• Updated Adult Asthma
• Laser Peripheral Iridotomy
• Intensive Hemodialysis
• Peritoneal Lavage