TWENTY three years have passed since the Filipino people first hoped for a program that would ensure their health. Over the years, the National Health Insurance Program (NHIP) has made various important strides to make sure that every Filipino is provided with financial risk protection against the ever-increasing cost of medical care services.
As the Philippine Health Insurance Corporation (PhilHealth) turns 23, take a look at some of the more significant programs, projects, linkages and technological innovations that created an impact on the NHIP’s various stakeholders.
Expanding membership mechanisms
Enrollment of Kasambahay, Senior Citizens, orphans and abandoned children, Dual Citizens and Foreign Nationals
PhilHealth firmly believes that everyone has the right to health; hence, the premier health insurer extends benefits to the rest of the population who are not yet covered. Now, PhilHealth has joined hands with the Department of Social Welfare and Deve- lopment (DSWD) to ensure that orphans, abandoned and abused children and other minor children are provided with social health insurance coverage. In addition, the Senior Citizens, Kasambahay and even dual citizens and foreign nationals living in the country are also covered.
PAyapa at MAsaganang PamayaNAn (PAMANA) Project
The enrollment of families under the PAMANA program of the government is a result of the collaboration with the Office of the Presidential Adviser on the Peace Process (OPAPP). The beneficiaries of members in the program are entitled to all benefits under the NHIP.
Sajahatra Bangsamoro Program
The Sajahatra Bangsamoro Program is a product of an agreement between the national government and the Moro Islamic Liberation Front (MILF), which aims to maintain peace in Mindanao through the implementation of health, education and livelihood programs. PhilHealth is one of the agencies implemen-ting the comprehensive agreement by exten-ding membership and providing social health insurance benefits under the Sponsored Program.
Point of Service (POS) / Point of Care (POC)
An allocated sum of P3 billion set into motion the Point of Service (POS) Program of PhilHealth in 2017. It granted PhilHealth coverage to Filipinos who do not have the means to pay for health services at the time of hospitalization. In 2013, a similar policy called Point of Care (POC) Program was implemented alongside the massive enrollment of the poor and elderly, which seeks to automatically provide social health insurance entitlement upon hospital admission after an assessment of the potential beneficiary.
Making SHI benefits matter
All Case Rates
The shift from fee-for-service to case rates for medical and surgical cases was prompted by developments taking place in the health care industry, most notable of which is the need to provide optimal financial risk protection especially to the most vulnerable groups, including the poorest of the poor. Under this payment mechanism, all compensable medical conditions and surgical procedures have a pre-determined fixed amount of benefits, thereby enabling members to know exactly how much PhilHealth will be paying for the illnesses that caused them their hospitalization or medical treatment.
Z Benefit Packages
The Z Benefit Packages aim to increase financial risk protection for PhilHealth members, especially the underprivileged, through the delivery of quality care using cost-efficient interventions that are based on approved clinical protocols and guidelines. The package includes treatment for certain types of cancer and other illnesses that are considered catastrophic in nature. It also ensures that patients are given the acceptable standards of care at the appropriate time. Now, there are 17 Z Benefits that may be availed of in PhilHealth-contracted hospitals and health care facilities.
No Balance Billing
In 2011, PhilHealth introduced the No Balance Billing (NBB) Policy, which provides that no other fees or expenses shall be charged to or be paid for by the indigent patients above and beyond what PhilHealth pays for. Today, this policy has been extended to sponsored members, Kasambahay, senior citizens and lifetime program members, to demonstrate what financial risk protection is, especially for the more vulnerable sectors of society.
Maximizing technological innovations
Electronic Premium Remittance System (EPRS)
Employers from all over the country are now benefiting from the Electronic Premium Remittance System (EPRS), a web-based innovation where generation of statement of account, online remittance of premium contributions and posting of payments have significantly unburdened the PhilHealth Employers’ Engagement Representatives (PEERs). Today, the remittance of premium contributions, as well as submission of remittance reports can be done online.
Electronic Claims (eClaims)
Electronic Claims or E-claims aims to provide health care institutions (HCIs) with the online capability to verify a patient’s eligibility for health insurance, submit claims electronically, and track the status of claim reimbursement. PhilHealth has accredited at least seven health information technology providers (HITP) to provide HCIs with the means to connect to PhilHealth and transact business electronically. For now, accredited HCIs may tap HITPs, electronic medical records, or in-house developed software solutions duly certified by PhilHealth to implement the eClaims.
All Case Rates Search Engine and Mobile Application
To keep up with the mobile app trend and to provide its clientele with ready access to information on benefits, PhilHealth created the All Case Rates Search Engine in 2015. Found in the homepage of www.philhealth.gov.ph, this facility provides details of and describes the illnesses and conditions, including the amount paid for by PhilHealth to accredited hospitals and doctors as well as the categories of hospitals, where the benefits may be availed of. The same access is now available for Android mobile phone users through the ACR Search Engine Mobile App.
Member Inquiry Facility
Members of PhilHealth may now check on the accuracy of their member data records (MDR) through the Member Inquiry Facility that can be found on the homepage of www.philhealth.gov.ph.
The facility allows members to verify the accuracy of the information reflected in their membership profiles such as name, date of birth, address, employer, names of dependents, and other pertinent personal details.
In 2014, PhilHealth required its accredited HCIs to install the HCI Portal, which serves as an electronic gateway. The HCI Portal simplifies the filing of PhilHealth claims and availment procedures by reducing documentary requirements. The PhilHealth Benefit Eligibility Form (PBEF), which the portal generates, replaces the MDR and ascertains the eligibility of the member or his dependents to avail of the benefits at point-of-service. Today, about 90 percent of accredited hospitals nationwide are using the HCI Portal.
24/7 Action Center
The PhilHealth Call Center started operating round-the-clock in August last year to address stakeholders’ concerns, especially those needing immediate responses. Members may now call the 24/7 hotline to inquire about their membership, how and where to avail of be-nefits, and other concerns.
Promoting quality standards
The enhanced Benchbook for accredited HCIs aims to ensure that quality service is provided to PhilHealth members. The Benchbook two categories focusing on the assessment of the capability of each facility, which may want to be part of the implementation of the NHIP; first is the “Patient-Centered Standards” with seven aspects and the “Facility-Centered Standards” with six aspects.
Health Care Provider Performance Assessment Standards (HCP-PAS)
PhilHealth continues to strengthen the mechanisms to monitor the performance of accredited health care providers (HCPs), assess the outcomes of the services they render and provide feedback to the HCIs as well as to the public. The HCP-PAS aims to standardize the process of monitoring if the accredited health care facilities respond to their commitments to the NHIP in terms of providing medical benefits with the correct level of quality and responding to financial protection against the high cost of medical expenses.
Honoring service quality
ISO 9001:2008 Certified
As one of the government agencies with at least 90 million members relying on its services and social health insurance benefits, PhilHealth takes pride in being an ISO 9001:2008 certified in all its offices nationwide. The certification is being granted to organizations that demonstrated high standards of customer service with a commitment to continuously innovate to further meet the expectations of their clients.
ARTA Frontline Service Champion
PhilHealth was recognized by the Civil Service Commission (CSC) as one of the Frontline Service Champions or leading government agencies in the implementation of the Anti-Red Tape Act or ARTA Program this year. PhilHealth was also awarded as one of the “Seal of Excellence Hall of Famers” due to the 67 SEA Awards it garnered from the CSC.
Four special recognition awards were granted to PhilHealth during the 34th Asean Social Security Association (ASSA) Board Meeting held in Thailand. These are the Customer Service Recognition Awards for the Guaranteed Health Benefits and Priority Settings to Maximize Health Outcomes and All Case Rates Search Mobile Application; Innovation Recognition Award for the Institutional Health Care Provider Portal; and the Strategic Communication Recognition Award for the Development of PhilHealth Learner’s Material for the Basic Education Program of the Philippines: Planting the Seed of Sustainability.
Philippine Government Best Practice
The PhilHealth Customer Assistance, Relations and Empowerment Staff or PCARES project was recognized in the Philippine Government Best Practice competition organized by the Development Academy of the Philippines. As one of the winners, the PCARES automatically gained a slot in the 4th International Best Practice Competition organized by the Center for Organizational Excellence Research of New Zealand.
Compliance to Freedom of Information
PhilHealth was recently certified by the Presidential Communications Operations Office as compliant to the Executive Order mandating the practice of Freedom of Information to ensure transparency in government operations.
Providing policy support
Revised Quasi-Judicial Provisions
The revisions covered Sections 75-188 of the IRR which primarily dealt with the quasi-judicial powers of PhilHealth in relation to violations committed by stakeholders consisting of healthcare providers, healthcare professionals and members against the PhilHealth Charter and its IRR, PhilHealth Issuances and other policies relative to the implementation of the NHIP. The IRR revision was primarily undertaken to streamline administrative processes to facilitate and hasten the disposition of administrative cases filed before PhilHealth against healthcare providers, healthcare professionals and members for a more efficient implementation of the NHIP.
Strengthening information dissemination
PhilHealth Learner’s Manual
PhilHealth has initiated a full-scale partnership with the Department of Education (DepEd) in order to integrate the social health insurance (SHI) module in the basic to tertiary education curriculum. The program was first introduced to students in the tertiary level of Sultan Kudarat Educational Institution (SKEI) in Tacurong, Sultan Kudarat in 2015 and was later implemented in Rizal High School in Pasig City for their basic education in the same year.
On October 25, 2017, PhilHealth’s weekly TV program, “Kalusugan Mo, Sagot Ko” first aired on People’s Television 4. Aired every Wednesday from 10:00 am to 10:30 am, the TV program aims to further spread relevant information regarding the NHIP so that more members will learn about the NHIP and PhilHealth.