Posted: April 3rd, 2022

Impact of the PhilHealth Z Benefit Package Implementation

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Monetary Impact of the PhilHealth Z Benefit Package Implementation in Two DOH-Retained Hospitals

Creator

Alvin S. Concha, MD

Co-author

Jaryll Gerard L. Ampog

INTRODUCTION

Matter background

One of the strategic thrusts of the Division of Well being is “monetary threat safety by way of growth in Nationwide Well being Insurance coverage Program enrollment and profit supply (DOH, 2010). Philippine Well being Insurance coverage Company (PhilHealth) is the duly mandated government-owned company to manage the Nationwide Well being Insurance coverage Act, which is aimed to offer common monetary entry to well being providers amongst Filipinos (RA 7875).

In September 2011, PhilHealth began to implement new case-based cost (CBP) schemes for 12 surgical and 11 medical circumstances. A no-balance-billing coverage was additionally imposed on all authorities hospitals for implementation amongst PhilHealth members from sponsored applications, primarily comprised of indigent individuals (PhilHealth, 2011).

In June 2012, PhilHealth created one other set of profit packages with CBP schemes referred to as the PhilHealth Z Benefit Packages (PZBP). 4 situations which might be thought-about medically and financially catastrophic had been initially included in the record of situations with Z profit packages (PhilHealth, 2012b). One other 5 situations had been added in 2013 (PhilHealth, 2013a; PhilHealth, 2013b) and two extra situations had been added in 2014 (PhilHealth 2014a; PhilHealth, 2014b) to the record. A hard and fast reimbursement charge was set by PhilHealth for every of the situations included in the PZBP record. PhilHealth additionally set a set co-pay quantity for every situation. The implementing well being facility can accumulate the allowed mounted co-pay quantity from non-sponsored members and their certified dependents. The no-balance-billing (NBB) coverage is utilized to all sponsored members and their dependents. Desk 1 exhibits the record of situations with Z profit packages and corresponding specs as of September 2014.

Desk 1. Listing of situations with Z profit packages and corresponding specs as of September 2014.

Abbreviations: ALL– acute lyphocytic (lymphoblastic) leukemia; CABG– Coronary artery bypass graft surgical procedure, commonplace threat; Cervical most cancers A– Chemoradiation with cobalt and low-dose brachytherapy or main surgical procedure for Stage IA1, IA2-IIA1; Cervical most cancers B– Chemoradiation with linear accelerator and high-dose brachytherapy; PD First– Peritoneal Dialysis First; PHC– PhilHealth Round; TOF– Complete correction of Tetralogy of Fallot (for youngsters); VSD– Closure of ventricular septal defect (for youngsters); Z MORPH– Mobility, Orthosis, Rehabilitation and Prosthesis Help.

Overview of associated literature

Supplier cost schemes

A supplier cost mechanism is the scheme of transferring funds from the well being care service purchaser to the well being care supplier (Cashin et al, 2005). When a person who has paid premiums for medical health insurance must entry well being care providers lined by the insurance coverage, the insurance coverage firm funds the well being care providers and pays the well being care supplier in response to a pre-defined supplier cost mechanism (GIZ, 2011a). Payment-for-service (FFS), case-based cost (CBP), line merchandise finances ant capitation are all examples of a supplier cost mechanism (GIZ, 2011b).Other than the switch of funds, supplier cost mechanisms additionally facilitate the attainment of well being coverage aims by creating incentives, supporting info programs and purchaser supplier accountability mechanisms that have an effect on well being care useful resource allocation service supply (Cashinet al, 2005; Econex, 2010).

Payment-for-service scheme

Previous to September 2011, to fund virtually all remedies and procedures, PhilHealth paid well being care suppliers of its members utilizing a fee-for-service scheme. Beneath this scheme, the well being service suppliers are paid for every reported service enter, exercise or use of objects in the direction of therapy of illnesses or efficiency of procedures (Sutherland, 2011). The charges for well being care on this scheme should not mounted (Langenbrunner et al, 2009). The larger the quantity of actions or use of objects, the greater the healthcare suppliers’ revenues are (ACHE, n.d.).

Case-based cost scheme

In a case-based cost mechanism, akin to the PhilHealth Z Benefit Package, well being service suppliers are paid a pre-determined mounted quantity (case charge) per case or episode of care (GIZ, 2011b; Langenbrunner et al, 2009). The cost is meant to cowl all inputs and actions inside the complete episode of care (Reinke, 2007). As a result of the cost is mounted, restricted and prospectively set, well being care suppliers face larger monetary threat in CBP than in FFS (GIZ, 2011b; Langenbrunner et al, 2009; Maciera, 1998).

Commerce-offs between FFS and CBP

Monetary threat for suppliers and well being care purchasers, in addition to stakeholder incentives, paperwork and system effectivity all fluctuate amongst totally different supplier cost mechanisms (Cashin et al, 2005; Mihalik et al, 1998). Implementing or shifting from one supplier cost mechanism to a different can even contain varied difficulties (Mathauer et al, 2013).

Whereas an FFS scheme includes low monetary threat to well being care suppliers, well being funders akin to insurance coverage firms could face excessive monetary threat on this cost mechanism (GIZ, 2011b). This scheme encourages nice volumes of providers, typically past what is named for (Cashin et al, 2005). This includes excessive prices for well being funders and yield excessive revenues for suppliers, but it surely doesn’t promote top quality and environment friendly well being providers (Langenbrunner et al, 2009; Reinke, 2007; Sutherland, 2011).

On the different hand, a CBP mechanism creates incentives for well being care suppliers to be environment friendly (i.e., decrease service enter) and to extend the quantity of circumstances (Langenbrunner et al, 2009; Maciera, 1998). Environment friendly suppliers revenue from the distinction between the case charge and the precise value of care (Sutherland, 2011). CBP can be related to a lower in the common size of keep of sufferers in the well being care facility (Langenbrunner et al, 2009; Sutherland, 2011), however has not been proven to lower the high quality of care. But, there was blended proof for a decrease value of well being care per episode inside a CBP scheme (Sutherland, 2011).

In a CBP scheme, the adequacy of the prospectively set cost, which is normally decided by way of statistical modeling and stakeholder consultations, may be vulnerable to arguments. As a result of of the mounted nature of the funds, inaccurate estimation of case charges could put well being care suppliers to a critical drawback (Mihalik, 1998).

Larger targets of well being coverage

There isn’t any single supplier cost mechanism that can work for any sort of well being system (GIZ, 2011b). It’s each well being system’s problem to work out cost mechanisms that contribute in the direction of the larger targets of well being coverage, most significantly, those who pertain to entry to top quality well being care providers, discount of monetary dangers and environment friendly use of well being care sources (Cashin et al, 2005; PhilHealth, 2012a).

Analysis Question Assignment/s

The research goals to evaluate the monetary affect of PhilHealth Z Package implementation in two DOH-retained hospitals specifically; Southern Philippines Medical Middle and Davao Regional Hospital.

Significance of the research

The PZBP is a CBP mechanism for situations which might be medically and financially catastrophic. Beneath the CBP scheme, a set supplier cost is about for a specific case or analysis. The mounted supplier payment is the quantity reimbursed by PhilHealth to the well being facility for treating an lively PhilHealth member. The reimbursement quantity is mounted, regardless of the precise prices that accrue throughout the course of therapy. In situations whereby the precise therapy value is lower than the mounted reimbursement payment, the well being facility good points revenue. When the precise therapy value is greater than the reimbursement payment, the well being facility loses revenue. This supplier cost scheme is meant to encourage well being services to make use of cost-efficient approaches to therapy. The advanced nature of the medical situations included in the Z profit package deal record, nevertheless, makes it tough for insurance coverage companies and well being care suppliers to foretell the precise value of care that every therapy entails.

To this point, we have no idea whether or not the Z profit package deal scheme effectively reimburses the well being care supplier with the precise value of care. There’s a want to find out the monetary affect of the PhilHealth Z profit package deal in establishments which have applied it. Monetary achieve by way of the scheme affirms the provision not solely of monetary threat safety to PhilHealth members, but in addition of environment friendly therapeutic approaches taken by the well being care supplier. A optimistic web revenue additionally leaves the well being care supplier with sufficient funds to enhance its providers. On the different hand, an expertise of revenue loss from the implementation of the scheme can ultimately have an effect on the funds and operations of the well being care supplier.

An excellent Assessment of the monetary affect of the scheme will facilitate the planning and implementation of measures inside the well being facility that can make its therapeutic approaches extra environment friendly. The Assessment may also inform PhilHealth of the adequacy of the initially set reimbursement charge of every of the situations in the Z profit package deal record. Most significantly, the Assessment will allow us to gauge whether or not or not the PZBP affords monetary threat safety to PhilHealth members who avail of it.

Goal/s

The primary goal of this research is to find out the monetary affect of the implementation of the PhilHealth Z Benefit Package in Davao Regional Hospital and Southern Philippines Medical Middle.

METHODOLOGY

Analysis design

This research will make the most of a descriptive design.

Setting

This research will probably be carried out in two DOH-retained hospitals. Davao Regional Hospital is a 200-bed tertiary care coaching hospital in Tagum Metropolis. Southern Philippines Medical Middle is a 1200-bed tertiary care coaching hospital in Davao Metropolis. The 2 establishments are 60 km aside.

Members

All PhilHealth sufferers from DRH and SPMC who’ve availed of the PZBP since the begin of every package deal implementation will probably be included on this research, and can represent the first half of the research pattern. An equal quantity of PhilHealth sufferers admitted proper earlier than the implementation of the PZBP with the identical diagnoses as these in the first half, however who had been billed on a fee-for-service foundation, will probably be chosen from amongst the sufferers in the identical hospitals. This latter group of sufferers will function the second half of the research pattern and comparability group.

Inclusion standards

Sufferers who’ve partially availed of case-based PhilHealth reimbursement (i.e., any of the 23 medical and surgical situations lined in the preliminary PhilHealth case charges of 2011) (PhilHealth 2011) for a analysis much like the situations in the PBZB record, however at a time when PBZP was not but applied, will probably be thought-about to have availed of a fee-for-service PhilHealth reimbursement. An instance for this can be a affected person who was recognized to have breast most cancers in 2011 (previous to PBZP implementation), who availed of the case charge supplier cost mechanism for modified radical mastectomy, however who paid for or availed of PhilHealth advantages for the subsequent chemotherapy on a fee-for-service foundation. For functions of this research, such affected person could be labeled into the fee-for service group.

Exclusion standards

Sufferers with incomplete billing information will probably be excluded from this research.

Sampling procedures*

Not relevant on this research

Interventions and comparisons*

Not relevant on this research

Randomization*

Not relevant on this research

Information gathering

Secondary information from sufferers’ hospital information will probably be the essential supply of information for this research. No direct affected person interviews or interplay will occur. The record of sufferers who acquired Z package deal advantages (PZBP group) will come from the PhilHealth Workplace of every hospital, which retains a log of PhilHealth members who’ve availed of the Z advantages since begin of PZBP implementation. The record of PhilHealth sufferers who had been admitted proper earlier than the PBZP implementation with the identical diagnoses as those that have availed of the Z advantages, however who had been billed on a fee-for-service foundation (FFS group) will come from the Medical Information Part of every hospital. All the hospital payments will come from the Billing Part of every hospital, and all the official receipts, assure letters, notes and PhilHealth reimbursement information will come from the Accounting Part of every hospital. Desk 2 exhibits the record of hospital information wanted for this research and the corresponding workplaces in the hospital the place the information will probably be obtained.

Desk 2. Hospital information wanted for this research and the corresponding workplaces in the hospital the place the information will probably be obtained.

Impartial variables

The hospital information will probably be reviewed to acquire the information mirrored in the case report kind (Appendix A).For every establishment (DRH, SPMC), the following outcomes, as operationally outlined, will probably be computed per situation per supplier cost mechanism (fee-for-service scheme previous to PZBP implementation; case-based scheme throughout PBZP implementation) for reporting:

Imply precise complete invoice – that is the common quantity of precise complete invoice mirrored in the abstract of costs in particular person affected person payments. The precise complete invoice represents the complete value of well being take care of a affected person with a specific situation.

Imply out-of-pocket funds – that is the common quantity of well being care value that’s paid by the affected person and/or different sources and isn’t reimbursed by PhilHealth. The person affected person’s out-of-pocket cost is inclusive of the precise quantity paid by affected person as mirrored in the official receipts and the precise quantity paid by different sources like PCSO, PDAF, MHCAP, and many others. Beneath the PZBP scheme, the out-of-pocket payment is termed “mounted co-pay”, as a result of PhilHealth has set a ceiling quantity, past which well being care suppliers should not allowed to cost sufferers.

Imply PhilHealth reimbursement – that is the common quantity of reimbursement acquired by the hospital from PhilHealth for treating a affected person with a specific situation. The person affected person reimbursements are anticipated to fluctuate in a fee-for-service scheme. In a case-based scheme akin to PZBP, the PhilHealth reimbursement quantity is mounted and predetermined.

Major consequence measures and different dependent variables

Imply hospital subsidy – that is the common quantity of the portion in the precise complete invoice that isn’t paid again to the hospital. The quantity is optimistic if the precise complete invoice is bigger than the PhilHealth reimbursement quantity plus the out-of-pocket payment. The hospital subsidy for particular person sufferers is inclusive of reductions, the unpaid stability and the quantity slashed by PhilHealth (if relevant). The hospital subsidy may be referred to as “damaging revenue”.

Imply web achieve – that is the common quantity of optimistic revenue. This quantity is optimistic if the precise complete invoice is lesser than the PhilHealth reimbursement quantity. In such occasion, no out-of-pocket cost is charged, the hospital doesn’t subsidize any quantity to cowl half of the well being care value and the hospital truly good points revenue.

Pattern measurement computation*

Not relevant on this research

Information dealing with and Assessment

Information for this research will probably be encoded in a spreadsheet and analyzed utilizing Epi Data 7. Steady variables will probably be summarized utilizing means ± commonplace deviation. Categorical variables will probably be summarized utilizing frequencies and percentages.

Moral concerns

Ethics Assessment

The protocol of this analysis will probably be submitted for approval to the Division of Well being XI Cluster Ethics Overview Committee (DOH XI CERC).

Confidentiality

Affected person information will probably be retrieved utilizing hospital case numbers and title initials offered by the respective PhilHealth Sections and Medical Sections of Davao Regional Hospital and Southern Philippines Medical Middle. Anonymized affected person information, devoid of personally-identifiable info like addresses, cellphone numbers, or e-mails, will probably be requested from the Billing Sections and Accounting Sections of the two hospitals. The info will probably be in each hardcopies and softcopies. Solely the investigators and research workers could have entry to the uncooked information. Hardcopies will probably be destroyed upon research closure. Softcopies will probably be saved by the principal investigator in a pc in a password-protected file. The complete research report won’t comprise affected person names or any personally-identifiable info.