CAGAYAN DE ORO CITY (PIA)--In the third year of strengthening the Universal Health Care (UHC) Law, and in celebration of PhilHealth's 27th anniversary with the theme, “Tumutugon sa Hamon ng Panahon,” Philippine Health Insurance Corporation (PhilHealth)-10 held an online discussion on UHC laws and benefits in PhilHealth Matters: A Webinar on the Universal Health Care, February 15.

Resource speaker Dr. Francis Ramos of PhilHealth-10 discussed the mandates from the UHC and proposed laws for 2022 and beyond.

A total of 34 UHC Integration Sites (USI) nationwide have been established, where four are located in northern Mindanao: Cagayan de Oro, Lanao del Norte, Misamis Occidental, and Misamis Oriental.

Over the years, he said, UHC focused on major concepts of immediate eligibility, global budget, primary care benefit package, contracting, health care provider networks, and interoperable health IT systems.

The first published circular based on the UHC Laws was the Philippine Circular No. 09 of 2019 or the Premium Contribution Schedule, the international standard of health coverage or insurance.

He explained, this deducts from members a minimum of 5% of the monthly basic salary for healthcare. To meet this, the legislators decided not to directly deduct 5% during its implementation but to gradually increase the premium rate each year: in 2019 (2.75%) was deducted, 2020 (3.00%), 2021 (3.50%), and 2022 (4.00).

Yet, since there is an occurrence of a pandemic, the 4% rate based on the schedule has been suspended to support and relieve members from large deductions. This 5% increase rate is proactive to philhealth’s initiative of expanding healthcare, focusing on out-patient benefits rather than on in-patient benefits.

There is also the release of Circular No.10, the Guidelines on Granting of Immediate Eligibility to Members. This means that every Filipino can now benefit from PhilHealth coverages whether they are PhilHealth members or not.

“Services first, and settlement after. Hospitals and healthcare facilities will give you services and benefits, but before you are discharged, you need to settle your membership and your premium contribution. No longer will hospitals ask for your eligibility, but they will give services first and settle the papers later,” Ramos said.

UHC amid COVID-19 pandemic

In the rise of pandemic in 2020, UHC Laws were continued to be realized and were kept on schedule.

New policies include the Individual Based Services or the Service Coverage where PhilHealth covers and provides benefits for spectrums of diseases, from mild to severe conditions.

Also to note in the previous years, PhilHealth has invested in in-patient settings, but in accordance with the UHC Laws, Philhealth and the Department of Health (DOH) have now invested more in the out-patient settings to prevent members and patients from becoming in-patients.

“We are promoting more healthy Filipinos if we intervene early in the disease,” Ramos explained.

In increasing emphasis on Primary Care Benefits especially for out-patients, PhilHealth Konsultasyong Sulit at Tama (KONSULTA) Package was developed.

Governing policies of KONSULTA under Circular No.02 of 2020 was established, followed by Circular No. 21 of 2020 for publishing the Accreditation of Health Care Providers (HCPs) for the Konsulta Package, and Circular No.22 for the Implementing Guidelines in operating the Konsulta Package.

Benefiting all Filipinos, Konsulta covers consultations, health screening and assessments, diagnostics, and medications. These will be provided by accredited infirmaries and hospitals, primary care facilities such as barangay health stations and rural health units, and includes stand-alone medical clinics.

No balance billing

In Circular No.24 of 2020, the Governing Policies on No co-payment / No balance billing for PhilHeath Benefit Packages was also implemented. This means that admitted members have no co-payment for basic services, other fees, and no expenses shall be charged for both public and private sectors.

After the implementing guideline for this circular is published, all facilities can then practice no balance bidding from both private and public sectors.

Circular No. 20 of 2020 on the other hand is the Governing Policies on PhilHealth Costing and Costing Methodology, shifting to Diagnosis-Related Group (DRG) to assess and classify diseases, and will be used as referencial bases to calculate costs and payments for diseases.

In 2021, PhilHealth developed the Health Care Provider Network (HCPN) with DOH. This has improved patient navigation, inter-facility coordination, maintaining quality health service, judicious health expenditure, and medical documentation.

Gatekeeping was also planned to be following Europe and North America’s so members and patients can be properly navigated into the health care system.

Health info network

There is also the Primary Care Provider Network, an inter-referral system for facilities to communicate and coordinate to intercept either healthy patients or sick and non-emergency patients of services. “In all of your engagements and interactions with these facilities, PhilHealth will be covering all of your engagements–this will be charged to the network,” Ramos said.

In development is the Health Data Center, a proposed system under the UHC that would integrate health information between higher facilities and smaller or non-hospital which each have IT systems that transmit information to PhilHealth. Documents, papers, and laboratory tests will no longer be needed for consultations as these records are integrated and will become accessible in the HDC for all facilities.

The governance of the health care provider network was also known to be fragmented, separated into local government units (LGUs), corporate, facilities under DOH, cooperatives, single properties, and partnerships. To unite this, PhilHealth has now implemented the Local Health Board (LHB) composed of the local chief executive, DOH, private sectors, and indigenous groups and people’s groups, which was proposed by the UHC for HCPN to be managed accordingly.

For 2022, UHC will be focusing on the financing system following the Global Budget proposed by the UHC, where health expenditures and claims of each care provider network will be calculated by PhilHealth and will become a referral on how much will be provided to networks.

PhilHealth has also recently received funding from Sin Tax, Philippine Amusement and Gaming Corporation (PAGCOR), and Philippine Charity Sweepstakes Office (PCSO) to be used for its benefit pool or fund pool. (RLT/PIA-10)