Alexander A Padilla, President and CEO, Philippine Health Insurance Corporation (PhilHealth): Interview

Interview: Alexander A Padilla

How can PhilHealth boost utilisation of the universal coverage programme among the unserved and underserved segments of the population?

ALEXANDER A PADILLA: In 2014 alone, the national government allotted P35.3bn ($794.3m) in premium contributions for 14.7m families, or roughly 46m individuals. Allocation will increase to P37.2bn ($837m) in 2015, as coverage is expanded to Barangay officials and – as part of the peace initiative – to the Moro Islamic Liberation Front and other qualifying political groups. To put utilisation in context, for every 100 members, around eight normally get sick, and covering their needs requires the resources of all contributors. As such, we do not aspire for 50% utilisation, as it would mean an epidemic.

For the poor, utilisation has increased from 7% to roughly 12%, accelerated by an information campaign. Traditionally, many of the poor have not known they are members of PhilHealth, though this trend is being reversed by efforts to coordinate with other government agencies to increase awareness. The goal is to help members learn about PhilHealth and demand their rights. Aside from the no balance policy, which helps the poor avoid out-of-pocket expenses after entering a hospital, we have point-of-care enrolment, whereby anyone who is not part of the listed poor under the Department of Social Welfare and Development or listed as formal sector can enter a hospital and enrol immediately with PhilHealth.

We have also come up with a new case rate system. Currently, we have a fixed amount for each treated medical case, ranging from P10,000 ($225) for dengue, to P8000 ($180) for normal childbirth and P19,000 ($427.5) for caesareans. In the past, we did not know the cost of public versus private hospitals or secondary versus tertiary ones. The new system now allows hospitals that are efficient and able to discharge patients in a timely manner to benefit from our case rate. The case rate not only protects members and increases hospital accountability, but also promotes a change in behaviour. For example, hospitals often complain that reimbursements for caesareans are low – which is true. However, with caesareans accounting for 56% of births and rising, mothers are in danger. As long as rates do not fall to acceptable levels, case rates will not increase.

What measures are being institutionalised to ensure health coverage and social protection for vulnerable groups and minimise out-of-pocket expenses?

PADILLA: In 2015 we will have a more systematic outpatient benefit package called Tsekap, whereby the poor and members of sponsored groups will be assigned to particular health facilities near them, which could be rural units or clinics, not just hospitals. Beneficiaries will be offered a range of services and diagnostics, including medication for the three most-common diseases – hypertension, diabetes and high cholesterol.

Whereas members used to have to go to a hospital to receive treatment, this allows them to enrol in a rural facility. Doctors and nurses have an obligation to administer Tsekap, while PhilHealth is strengthening its monitoring mechanisms to verify that services were received. Preventive care will also be a focus, helping to lessen the costs of curative or hospital treatment. Depending its success, it could be extended to all Filipinos.

We currently allow services to be provided by private institutions if the geographical area does not have a facility or if it is an island community, which is common in the Philippines. We are open to government institutions – not only to Department of Health hospitals, of which there are around 80 in the country, but also local government unit (LGU) hospitals and facilities, which number around 800. However, as LGU resources cannot fully cover their constituents because of other priorities in the community, PhilHealth represents the best additional resource for buying necessary equipment and paying local professionals, which can account for up to 40% of reimbursement fees. In addition, our Z catastrophic benefit package helps protect patients from high medical costs by capping private hospital outof-pocket expenses to match payments from PhilHealth.