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UNIVERSAL HEALTH CARE: PHILIPPINE CONTEXT - Coggle Diagram
UNIVERSAL HEALTH CARE: PHILIPPINE CONTEXT
Population coverage
every filipino citizen shall be automatically included in PhilHealth
direct contributor
self-earning individuals and practicing professionals
kasambahays
OFW
they can use PhilHealth in other countries as long as it is usable; if umuwi sila -> member sila
PWDs
all filipinos >=21 with capacity to pay
indirect contributor
indigent families identified by DSWD
National Targeting Household System for Poverty Reduction
targeted survey conducted every four years that identified poor households as a basis in identifying potential beneficiaries for social protection programs and services of the government
also used to identify 4Ps beneficiaries
pantawid pamilyang pilipino program
conditional cash transfer program
with conditions
list of indigent people
problems
does not accurately list all of the indigents
some are not eligible (kumpare ni kagawad)
information does not change every four years
beneficiaries of 4Ps
goal of 4Ps
to see if people will have a better life due to 4Ps
conditional, meaning if they fail to achieve this requirement, they will be expelled from the program
they can get health promotion programs
senior citizens
sangguniang kabataan officials
all filipinos >= without capacity to pay
service coverage
individual and population-based services
indiv-based: government should provide patient-centered care
PhilHealth pay for this
pop-based: vertical programs of DOH (vaccination)
DOH pay for this
benefit packages
examples
Konsulta+ Package
comprehensive outpatient benefit package (COBP)
created to harmonize existing primary care and outpatient benefit packages to emphasize preventive and promotive health service
includes
lab tests
consultation fees
patient navigation
selected services
prescription and emergency services
covers individual first
capitation
a provider payment mechanism where providers are paid a fixed amount prospectively to provide a defined set of good and services for each enrolled individual for a fixed period of time
case-based paymetn
a provider payment mechanism where providers are paid a fixed amount per episode of care, based on clinical condition/s
ex. kapag malala ang sakit, pwedeng mataas ibigay sa kanya
comprise of
PhilHealth Konsulta
package inclusions
screening and assessment
initial and follow up consultations
patient navigation
selected diagnostic services
prescription
emergency care services
disease-agnostic and comprehensive set of primary care services forming the base of Konsulta+
provider acts as
the chief facility at the primary level among its affiliate facilities
the patient navigator ensures first-contact, continuing and comprehensiveness care for all persons who are either diagnosed or undiagnosed, presenting any health concern
Standalone Outpatient Packages
disease- or intervention-specific bundles of services that can be provided as outpatient
SDG related
criteria
services for diseases that are endemic to specific localities
specific packages for HIV, TB
services that require medical equipment outside the requirements and capacities of primary care facilities
services that require specialized practice, training,or certification beyond the capacity of the primary care provider
Konsulta+ Network
priamry care provider facilities (PCPN)
RHU
free-standing private medical outpatient clinics
industrial clinics
school clinics
specialized outpatient facilities
ambulatory surgical clinics
animal bite centers
dialysis centers
TB-DOTS clinics
dental clinics
infirmaries
outpatient facilities of L1-L3 hospitals
diagnostic labs
pharmacies
considered as primary care facility; in DOH, it is considered as ancillary health facilities
konti lang gov pharmacy; most are private
if the private pharmacy is part of PCPN, pwede silang maaccredit ng PhilHealth -> reimbursement
other as indicated in applicable DOH and PhilHealth policies
Electronic Medical Record (EMR) System
only providers with a functional EMR system, that is interoperable with PhilHealth's systems, shall be contracted
capitation
may vary based on age and gender demographics of the catchment population of the Konsulta provider; location (e.g., GIDA communities), health facility classification (e.g., training or non-training), population size
performance-based payments
may be infused within the capitation scheme as appropriate and necessary to incentivize specific service provision and or outcome achievement
PhilHealth GAMOT Package
standalone outpatient benefit package with its own benefit rate and payment
cover select essential medicines used in the
outpatient
management of cases
not cover drug received as inpatient
specific for primary care
this benefit shall eventually form apart of the Konsulta+ as one of its standalone outpatient packages
cost sharing mechanism
medications dispensed shall be fully covered for the inital PhP 9 000 for each individual per calendar year
full utilization of the benefit coverage would allow beneficiaries to purchase the molcules following the benefits fixed fee schedule or with store prices.
OOP due to benefit utilization shall be subject to existing national policies on mandatory discounts, as applied by the GAMOT facilities
discounts must be considered by the facility: ex. patient purchases medicine at a discounted price of Php 15 (P20 previously), package cover only P10 of it and the remaining will be shouldered by the patient (P5). if not then, the OOP of the patient will be greater, will become P10
hence, it should be clear; what are the possible mechanisms should be used before the package can be used later on
prescription of medications
physician must register to the GAMOT Application
physician shall interview, examine, diagnose and prescribe laboratories and medications, as necessary
medication are prescribed through
GAMOT app, required
e-prescribing system
physical copy by direct printing of precription from GAMOT app or replicate handwritten prescription
bcoz not all have the access to application
Prescription may include all medications necessary for case management, but GAMOT Prescription coverage will only
apply for identified medicines
the P9000 will cover only those medicines listed on their package
Can only prescribe to a maximum quantity for 3 months per maintenance, and complete course of antibiotics for infections
dispensing of medications
GAMOT facilities shall cater to all PhilHealth members availing the PhilHealth GAMOT package, regardless of disease condition, location or address, and origin of prescription
GAMOT facilities: pharmacy accredited by the DOH
in other countries, there is a specific pharmacy where the patient can go, but in the case of the philippines, it would be difficult for the patient to allow him/her to go to a specific pharmacy; they can avail the package in any accredited pharmacy
upon access to the digital prescription in the GAMOT app, the RPh or PA shall counter prescription shall automatically render it void
RPh or PA shall verify eligibility for coverage and applicable cost sharing with payments to be made; annotate the quantity dispensed, quantity remaining, and the date of dispensing of claimed medications on the prescription both on the GAMOT app and the physical prescription
RPh will check how much left in pt's Php 9000, how much the pt's OOP
advantage of e-prescribing
medication history
clinical pharmacy services
prescription
maximum of 1 month, 2 months for GIDA communities
engagement eligibility
facilities with drug dispensing capacity and LTO from the FDA
are eligible to be engaged by a provider network to become a PhilHealth GAMOT facility
retail drugstores/pharmacies
hospital pharmacies
primary care facilities
FOURmula One Plus Botika ng Bayan (BNB) outlets of the DOH
should carry the medicines required by this package
questions
when to change the benefit packages
ways to compute the new rate
what are the new benefit packages
are there benefit packages at the specialty care and primary care level
referral system
PCPN
primary care provider network
includes
primary care facility
pharmacy
laboratories
infirmaries
expected to create a network, they should talk with each other
HCPN
health care provider network
includes hospitals and other facilities
should provide clear directions where to go from primary care facility to hospital
primary care provider
can be
doctor
pharmacist
nurse
patient navigator
provide information to patient where to go (e.g., dementia -> neurologist, psychiatrist)
all of healthcare services are covered except for personal gain (e.g., cosmetics)
Financial coverage
types of services
population-based
types
LGU population-based services
DOH population-based services
individual based health services
PhilHealth
copayment
a fixed amount paid after a consultation or confinement
set rate you pay for prescriptions, doctor visits, and other types of care
Php 7,500 copay
there is a specific amount to be paid by the insurance
coinsurance
an insured patient;s percentage share of the cost of a covered health expense
percentage of costs you pay after you gave met your deductible
30% coinsurance
percentage
PhilHealth
some RHU is PhilHealth accredited
however some RHU has limited capacity -> difficulty in accreditation
mahirap din maging license facility of the DOH, therefore mahirap din maging PhilHealth accredited
if di kaya, then sa LGU ngayon kukuha ng budget
predictability
how well spending on certain services can be anticipated
the payment should not be catastrophic
predictiveness
how well the predicted levels of certain services contemporaneously co-vary with total health care spending
share of the certain services to total OOP (10%, 50%, etc)
subfunctions
revenue raising
source of units
government budgets, insurance, OOP, external aid
pooling of funds
accumulation of prepaid funds on behalf of some or all of the population
purchasing of services
payment or allocation of resources to health services providers
population based or individual based
misconception
services are free
people tend to overuse the services, making it unavailable to those who really need it
Health service delivery
population-based health services
relevant law
SN 2620
dahil di nararanasan ung effect ng premium rate increase
basically, binabaan ang premium rate for a certain amount of time but mag-iincrease din in due time
pinaliwag paano babayaran ng
migrant workers
indirect contributor
wala sa RA 11223 dati
during state of calamity, what will happen to the premum rate
RA 11223
increase in the services that cover different diseases due to UHC law
ladderized premium increases (adequate funding)
every year, there is an increase in premium rates
primary care provider network with patient records accessible throughout the health system
PCPN should have accessible EMR
accurate, sensitive, and timely epidemiologic surveillance systems
intended to be received by populations or identified groups of people, of which outcomes contribute to the general public health, safety and promotion
rendered in response to a public health emergency or disaster or any circumstance of equal magnitude, such as diseases for elimination, that has affected, or can potentially affect, a population
ex. outbreak of mumps
the mayor can declare state of calamity and the money will be used to address the outbreak
proactive and effective health promotion programs or campaigns
individual-based health services
contract public, private, or mixed HCPNs for delivery of services
ex. ancillary pharmacy
they can partner with private pharmacy to provide such service
HCPNs agree to serve quality, copay/coinsurance, and data submission standard
Apex or end-referral hospitals may be contracted as stand-alone health care provider
end-referral hospital
provincial hospital
district hospital
HCP payments using performance-driven, close-end, prospective payments based on disease or DRGs and validated costing methodologies and without differentiating facility and professional fees
develop differential payment schemes that give due consideration to service quality, efficiency, and equity
kapag maganda performance, pwede bayaran
institute strong surveillance and audit mechanisms to ensure network's compliance to contractual obligations
definitely traced back to one recipient, has limited effect at a population level, and does not alter the underlying cause of illness
dapat nattrace back to the specific patient na nakareceive ng gamot or services
such services include, but are not limited to, ambulatory and impatient care, madicines, laboratory tests and procedures
strategies
HTA
ewan
Health Impact Assessment
a means of assessing the health impacts of policies, programs, and projects in diverse economic sectors before, during and after implementation
effects of social determinants of health
impact on people's health
located in Health Sensitive Areas
Disease-endemic areas or emerging hotspots for vector-borne diseases
Areas with limited local health care system
Areas vulnerable to natural or climate occurrences
Areas designates as tourism sites or areas whose natural resources are used for tourism purposes
Areas of indigenous and ancestral domains, or areas traditionally occupied by cultural communities
Areas where local communities derive their livelihood and basic needs|
Areas designated as industrial towns, zones, sites, or areas with multiple development projects in
operation
Areas whose land is converted for housing and resettlement purposes
IP and GIDA
HIA automatically conducted
Health Sensitve Project
based on the DENR's categories of "Environmentally Critical Projects" pursuant to the applicable provisions of EMB Memo Circular No. 005 s. 2014. Adopting the DENR's project categories for this purpose shall be done without prejudice to the subsequent updates to the guidelines that will be issue.
DOH AO No. 2020-0058
Social determinants of health
includes many factors outside of health systems
socioeconmic factors
globalization and urbanization
demographic patterns, environments (physical, legal, economic, and political)
patterns of consumption
commercialization and trade
climate change
family structures
culture and fabric of societies
kapag may bagong developmental project, automaticallu need ng HIA
Organization of Local Health System
special health fund
sources
financial grants and subsidies from NG agencies, such as the DOH
income from PhilHealth payments
financial grants and donations from non-government organizations, faith-based organization, and official development assisstance
incentives
NG shall make available commensurate financial and non financial matching grants, including capital outlay, human resources for health and health commodities, to improve the functionality of province-wide and city-wide health systems
concept pa lang not implemented
required na gamitin for healthcare
regulation
safety and quality
rating system under an incentive scheme to acknowledge and reward facilites that provide better quality, efficiency, and equity
licensing and regulatory system for stand-alone facilities
standards for clincal care through clinical practice guidelines (CPGs)
to ensure clinical care is of good quality
affordability
DOH-owned healthcare providers
shall procure drugs and devices guided by DPRI, following centrally negotiated prices, sell them following prescribed maximum mark-ups, and submit to DOH a price list of all drugs and devices
Independent price negotiation board
representatives from DOH, PhilHealth and DTI, among others, shall be constituted to negotiate prices
dapat meron din sa LGU
Health care providers and facilities
required to make accessible up-to-date infomation regarding prices of health services, and all goods and servieces being offered
drug outlets
required to carry generic equivalent of all drugs in the primary care formulary
equity
DOH shall annually update underserved areas
prefential licensing of health facilities
especiallu in GIDA
contracting of health services
government shall guarantee that distribution of health services and benfits provided by prioritizing GIDAs in the provision of assistance and support
bed capacity as basic or ward accomodation
all governments hospitals
NLT 90%
specialty hospital
NLT 70%
private hospitals
NLT 10%
Key actions to reducing health inequities by improving primary care service
prioritize the marginalized, ensure no one gets left behind
targeting the marginalized must be intentional
LGUs can leverage regular services in registering individuals; piggy-backing FPEs in regular public health programs
improve health data to include health equity indicators
dapat ibigay ang knowledge sa kanila about these services
collaborate to address technical challenges to improve the quality of primary care services
engage the private sector to improve access to primary care by ensuring portability and interoperability of Konsulta and other health programs
ex. immunization by pharmacist using gov procured vaccines
di kaya ng public sector, kailangan ng help from private sector
multiply efforts and increase capacity to reach far-flung communities, e.g., train BHWs to conduct FPEs, improve performance by setting daily targets, and provide
performance-based incentives
sustain investments in primary care service
increased investments in improving faciltiees, HRH, health information, and service delivery will improve the supply side of primary care
kailangan improve always ang facilities
train HRH on necessary skills
aim is to feel the change brought by UHC law but it will take long time