Philippine Health Insurance Corporation

In 2010 and 2015, reform efforts were outlined to make decentralization and health insurance work more effectively, including an expanded government subsidy for the enrollment of the poor, the creation of local health service delivery/planning units to reduce fragmentation, and a stronger DOH role in regulation.[5] Also the shifting from Fee-for-service to Case Rate payment scheme and IHCP Portal System is established to provide a link between accredited institutional health care providers and Philhealth through online connections.

PhilHealth has six major membership categories covering nearly the entire population. Those who count under the (1) "Formal" sector are workers employed by public and private companies and other institutions. (2) "Indigents" also called "Philhealth sa Masa" are subsidized by National Government the National Household Targeting System for Poverty Reduction. (3) "Sponsored Members" are subsidized by their respective Local Governments (LGU). (4) "Lifetime" (non-paying members) are retirees and pensioners and have already paid premiums for 120 months of membership and are 60 or older. (5) "Senior Citizen" under RA 10645 that all citizens ages 60 years old above are eligible to have free PhilHealth coverage. (6) The "Informal Economy" is composed of Informal Sectors, Self-Earning Individuals, Organized Group, Filipino with Dual Citizenship, Natural-Born Citizen. Although treated separately, the Overseas Filipino Workers (OFW) program or Migrant Workers are a part of the Informal Economy. Migrant Worker is sub-categorized as whether land-based or sea-based (for seafarers).

Since 1996, the benefits package and delivery system have improved. PhilHealth now has an Outpatient and Diagnostic Package limited to indigent beneficiaries. This addition creates nearly comprehensive coverage for indigents. In 2011, 23 CASE RATES was introduced and in 2013, ALL CASE RATES was fully implemented. All other beneficiaries have access to nearly comprehensive services, excluding some outpatient care. PhilHealth has an accreditation program for private hospitals.[6]

Some key reform indicators to date include:

• Estimated coverage is 100% as of June 2013
• Average period for payment of providers is estimated at 70 to 75 days. The law requires PhilHealth to reimburse providers and/or members within 60 days. A recent move as of December 1, 2009, implemented a “simplified reimbursement scheme” wherein 95% of the amount of the claim is reimbursed after a rapid assessment of member and provider eligibility and the remaining 25% follows after detailed review of the claims.

On average, 90 out of every 100 claims are paid, 3 to 4 are denied, and 6 to 7 are returned to health care providers for more information. 28% of claims were submitted by public providers and 72% by private providers.[7]

Funding varies based on the population covered, although the majority of funds flow from general taxation. Premiums from the formal sector reach up to 3% of monthly income. Premiums from both the poor and the informal sector are 2,400 pesos annually (about 50 USD). However, the cost of insurance for the poor is fully subsidized by the central and local governments. The National government allocates more than 9 billion pesos annually to meet its target.[8]

All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The national government payment is dependent on the availability of funds.

The benefits package is essentially the same for each membership category, PhilHealth deduction will depend upon the final diagnosis. The exception is for indigents and Overseas Filipino Workers (OFWs) who have additional outpatient primary care benefits (with the providers paid by capitation) however these benefits are available only through public providers.

PhilHealth and beneficiaries have access to a comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to outpatient primary care benefits (PCB1) or TSEKAP.

Inpatient care includes room and board, medicines, diagnostic and other services, professional fees and operating room services under the "all case rate" payment scheme. The case rate amount will depend upon the final diagnosis and each diagnosis has a corresponding fixed amount or package. The case rate amount shall be deducted by the HCI from the member's total bill, which shall include professional fees of attending physicians, prior to discharge. Catastrophic conditions, ambulatory surgeries including ambulatory dialysis, deliveries and outpatient malaria and TB-DOTS care.

Outpatient benefits include day surgeries, radiotherapy, dialysis, outpatient blood transfusion, TB-DOTS, malaria treatment, HIV/AIDS treatment, animal bite treatment, cataract operations and vasectomy and tubal ligation.

Except for the outpatient primary care benefits (PCB1) that the indigents and OFWs are entitled to via public providers, patients have free choice of providers, both public and private.

Annual or lifetime coverage limits exist. These limits are expressed in terms of volumes of services (e.g., days) rather than a peso coverage limit. For example, principal member are eligible for 45 days of inpatient admission and also outpatient, and another 45 days to share among its qualified dependents. Each day of ambulatory surgery counts as a day of admission.

Providers are allowed to charge the patient the difference between the total cost of care and what PhilHealth pays (i.e., balance billing).

Indigent and sponsored members, lifetime members, senior citizen members and household members are entitled to avail the free hospitalization under the no-balance billing scheme (NBB) when they are admitted in a non-private room of public or government hospitals. NBB are not applicable under private rooms and private hospitals so members have to pay the excess or balance after the case rate amount has been deducted.

The service delivery system includes both public and private centers; on average, 61% of the network's providers are private and 39% are public. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health.

The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB-DOTS and malaria, and private TB-DOTS clinics.

Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth.

The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services.

PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector.

PhilHealth has a governing board of 13 individuals, chaired by the Secretary of Health, with the President and CEO of PhilHealth as Vice-Chair. While the law, RA 7875, that created the National Health Insurance Program provides that the President and CEO has a fixed term of 6 years, with the passage Republic Act 10149 or the "GOCC Governance Act of 2011," the President and CEO of PhilHealth now has a term of one (1) year (Section 17, RA 10149) to be elected among the ranks of the Board of Directors and subject to the disciplinary powers of the Board and may be removed for cause (Section 18, RA 10149).

Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses.

Congress mandated that the National Institutes of Health (based at the University of the Philippines Manila) to conduct studies to verify and validate performance.

Provider payment methods differ based on the illness or diagnosis. Case Rates are used for inpatient care, most day surgeries, and ambulatory procedures, TB-DOTS treatment, malaria care, deliveries, surgical contraception, and cataract surgeries, while primary care benefits providers are reimbursed based on a capitation system.

No formal system sets deductibles or co-payments for beneficiaries, but health care providers are allowed to “balance bill”, charging patients the balance between what PhilHealth pays and the total cost of care. This is atypical of most government health programs around the world and can lead to abuse by providers (e.g., overcharging) and thus limited access for the poorest. At the same time, balance billing allows providers additional cost recovery in the case that the reimbursement for services does not cover their cost.

PhilHealth conducts its own monitoring and evaluation, though the law mandates that University of the Philippines National Institutes of Health engages in monitoring of the scheme. Evaluations on the PhilHealth program are ongoing.

The Department of Health (to which PhilHealth is an attached agency) monitors and analyses data, including number and value of claims, number of accredited providers, number and value of premiums paid, number of members, etc.

In 2013 fraudulent claims Juan Miguel of Regional 1 started fire with against the state-health insurer were estimated at 4 billion pesos. However, the state failed to prosecute erring doctors, private and public hospitals, and public officials. AFP Medical Center, St. Luke’s Hospital, Philippine Orthopedic Hospital, University of Sto. Tomas Hospital, East Avenue Medical Center, Cardinal Santos Medical Center, Medical City, National Kidney and Transplant Institute, General Santos Doctors Hospital (GSDH) were investigated for health insurance fraud.[11] In Iloilo, eye-doctor claims for 2, 071 operations in 2006 amounting to PHP16 million in professional fees were also investigated. A hospital in Davao City also noticed that a janitor, not a PhilHealth member, had been lying in bed to claim benefits as a PhilHealth-accredited patient.[12] Also in 2006, PhilHealth revoked the accreditation of Sara Medical Clinic in Midsayap for admitting ghost patients.[12] 2018, A lawmaker was shocked to find out that Philhealth interim president Celestina Dela Serna spent one year living at a hotel worth P3,800 per night instead of renting a condominium unit or apartment in Metro Manila. Negros Oriental Rep. Arnulfo Teves said he and House Speaker Pantaleon Alvarez had the chance to talk to Dela Serna during an event at the House of Representatives, and they were appalled at her extravagant lifestyle. “She admitted to staying in the hotel for one year or more… More or less one year sa hotel siya nakatira charged to Philhealth and she said she thought it was okay, that’s why she did it,” he said. Teves said Dela Serna told him and Alvarez that she stayed at Legend Villas, where rooms are worth at least P3,800 a night.[13]

The Philippine Medical Care Program began in 1971 following the Philippine Medical Care Act of 1969.[14] It mandated creation of the Philippine Medical Care Commission (PMCC). In 1990, bills were passed that led to significant improvement of public health care insurance. House Bill 14225 and Senate Bill 01738 became Republic Act 7875, known as "The National Health Insurance Act of 1995". Approved by President Fidel Ramos on February 14, 1995, this become the basis of the Philippine Health Insurance Corporation.[15] On its 16th anniversary, the song "PhilHealth: Tapat na Serbisyo, Tapat na Benepisyo, Lahat Panalo" was introduced.[16]

• PhilHealth official website
• Department of Health Philippines website
• The Revised Implementing Rules and Regulations of the National Health Insurance Act of 2013 (RA 7875 as amended by RA9241 and 10606)