OBJECTIVE

This study aims to determine the clinical profile and incidence of in-hospital outcomes of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP).

A retrospective descriptive cohort study. A review of medical records was done from July 2017 to October 2023 to collect data and in-hospital outcomes of patients who underwent CABG surgery under Z benefit package.

One hundred twenty-six patients were included in the study. The mean age of patients was 60 years and majority of them were male and came from NCR. Hypertension was the leading cause of comorbidity. The top two most common in-hospital outcomes were hospital-acquired pneumonia and postoperative atrial fibrillation. Most commonly observed caused of increased length in hospitalization was pneumonia. The mean Society of Thoracic Surgeons (STS) (operative mortality) and Euro scores were 1.04 ± 0.82 and 0.88 ± 0.56, respectively. All patients had successful surgical outcome with no mortality and an average length of stay in the hospital of six days.

This study will serve as a future reference to enhance screening criteria and improved in-hospital outcomes for those who will undergo CABG under Z benefit package. The study also showed insights on clinical profile and in-hospital outcomes of patients who underwent CABG in our own institution and this may give way to a larger scale of study involving multiple centers who also offer the said program.

OBJECTIVES

The burden of oral diseases is high in the Philippines. The global burden of disease study in 2019 estimated that 44 million Filipinos are affected by oral disorder. More specifically, 29 million Filipinos have untreated dental caries. Outpatients' dental health services are not covered by PhilHealth benefit package. There is a need to include key oral health interventions such as basic prevention and treatment in PhilHealth benefit package to be delivered at the primary health care settings (WHO TSA 153980). The study aimed to determine the incremental cost-effectiveness ratio (ICER) of a set of oral health care services to be delivered at different levels of health care within a comprehensive PhilHealth benefit package.

This study evaluates the cost-effectiveness of including basic oral health services in the PhilHealth benefit package using a Markov modelling approach. The target population consists of Filipino adults and children at risk for dental diseases who are potential beneficiaries of PhilHealth. The intervention under consideration includes dental consultation, oral prophylaxis, topical fluoride application, silver diamine fluoride application, dental filling, and tooth extraction. The comparator is the current standard of care, which involves out-of-pocket payments for oral health services or limited access to subsidized dental care. The primary outcomes assessed include the incremental costeffectiveness ratio (ICER) per quality-adjusted life year (QALY) gained. A Markov model was constructed with a time horizon of 50 years to simulate the lifespan of Filipinos up to the average life expectancy of 70 years old, using a cycle length of one year to reflect disease progression and treatment effects overtime. Model parameters were derived from literature and expert opinion. Sensitivity analyses, including one-way and probabilistic sensitivity analyses, were conducted to assess uncertainty in model inputs. The analysis was carried out from a societal perspective incorporating direct medical and non-medical costs, and indirect costs.

A Markov model showed that a subsidized package is a cost-effective approach compared to the current situation of no subsidy, with an ICER of PhP 75,636 (1,535.76 USD) per disability adjusted life year (DALY) averted. The computed ICER was considered good value for money as it was below 2021 GDP per capita of the Philippines of PhP 174,286 (3,538.80 USD). One-way sensitivity analysis showed that the cost of preventive treatment had the most significant impact on the model, and a price threshold of greater than PhP 3,062 (62.17 USD) for preventive treatment will render the subsidized package no longer cost-effective. The budget impact analysis showed a 1.63% increase in budget annually with the current situation of no subsidy. Rolling out a subsidized oral health package will entail a significant increase in government expenses during the first year but a decreasing trend of 1-2% annually for the following years as the program takes its effect.

A subsidized oral health package is a costeffective approach from a societal perspective. It will entail a significant increase in government expenditure during the start of its roll out but will eventually result in a decreasing trend of expenses as the years progress.

BACKGROUND

PhilHealth serves as the Philippines’ national health insurance provider and is central to implementing the Universal Health Care (UHC) Law. Despite this, existing gaps and ongoing challenges in claims and financial management systems continue to affect public healthcare facilities’ operations and sustainability.

This article examined the effectiveness and challenges of PhilHealth’s claims and financial management systems in public healthcare facilities, focusing on accreditation, claims processing, reimbursements, and financial governance.

A qualitative multiple-case study design was employed in Quezon City and the provinces of La Union, Sorsogon, Leyte, and Bukidnon, with data collected from 2022 to 2023. Prior to data collection, a certificate of exemption was granted by the Department of Health – Single Joint Research Ethics Board (DOH-SJREB). Data were collected through key informant interviews with healthcare facility heads, claims processors, and PhilHealth personnel, supplemented by document reviews and facility observations. Thematic analysis was employed to examine the implementation of national health insurance policies at the facility level.

Accreditation standards are uniformly defined, yet compliance varies widely, directly influencing reimbursement outcomes. Facilities with compliance gaps often face provisional accreditation, downgrades, or suspension, resulting in reduced revenue. Although the Universal Health Care (UHC) Law guarantees patient access to PhilHealth benefits, the efficiency of claims processing remains uneven and highly dependent on administrative capacity, staffing adequacy, and digital infrastructure. Systemic inefficiencies at both PhilHealth and facility levels contribute to delays and claim denials. Reimbursements are further constrained by outdated case rate ceilings, inconsistent financial practices, inadequate recordkeeping, weak information systems, and poor storage conditions—particularly in lower-level hospitals and rural health units.

Reforms in claims processing workflows, information system integration, and financial management capacities are crucial to enhance reimbursement efficiency. Strengthening these systems is fundamental for supporting sustainable, equitable, and high-quality healthcare delivery in the public sector within the Universal Health Care (UHC) framework.

BACKGROUND

The Philippine Primary Care Studies (PPCS) is a network of pilot studies that developed, implemented, and tested strategies to strengthen primary care in the country. These pilot studies were implemented in an urban, rural, and remote setting. The aim is to use the findings to guide the policies of the national health insurance program (PhilHealth), the main payor for individualized healthcare services in the country.

The objective of this report is to compare baseline outpatient benefit utilization, hospitalization, and health spending, including out-of-pocket (OOP) expenses, in three health settings (urban, rural, and remote). These findings were used to contextualize strategies to strengthen primary care in these three settings.

Cross-sectional surveys were carried out using an interviewer-assisted questionnaire on a random sample of families in the urban site, and a stratified random sample of households in the rural and remote sites. The questionnaire asked for out-patient and hospitalization utilization and spending, including the OOP expenses.

A total of 787 families/households were sampled across the three sites. For outpatient benefits, utilization was low in all sites. The remote site had the lowest utilization at only 15%. Unexpectedly, the average annual OOP expenses for outpatient consults in the remote site was PhP 571.92/per capita. This is 40% higher than expenses shouldered by families in the rural area, but similar with the urban site. For hospital benefits, utilization was lowest in the remote site (55.7%) compared to 75.0% and 78.1% for the urban and rural sites, respectively. OOP expenses per year were highest in the remote site at PhP 2204.44 per capita, probably because of delay in access to healthcare and consequently more severe conditions. Surprisingly, annual expenses per year for families in the rural sites (PhP 672.03 per capita) were less than half of what families in the urban sites spent (PhP 1783.38 per capita).

Compared to families in the urban site and households in the rural sites, households in remote areas have higher disease rates and consequently, increased need for outpatient and inpatient health services. When they do get sick, access to care is more difficult. This leads to lower rates of benefit utilization and higher out-of-pocket expenses. Thus, provision of “equal” benefits can inadvertently lead to “inequitable” healthcare, pushing disadvantaged populations into a greater disadvantage. These results imply that health benefits need to be allocated according to need. Families in poorer and more remote areas may require greater subsidies.

Objective: This study aims to explore and analyze the modern contraceptive use of National Health Insurance (NHI) participants before and during the COVID-19 pandemic in South Kalimantan, Indonesia. Methods: This research is an ecological study using aggregated data from 13 Districts/Cities in South Kalimantan. This study used secondary data in 2018-2020 from the official website of the National Population and Family Planning Agency. Spatial analysis and paired T-test were used. Results: There were 30.7% of Districts/Cities in stagnation and 30.7% in the decline of modern contraception use during the pandemic (2019-2020). In addition, the study showed that there were differences in the use of modern contraception before (2019) and during the COVID-19 pandemic (2020) among active family planning acceptors of NHI participants (p=0.048). Conclusion The existence of NHI, especially recipients of contribution assistance, can increase the use of modern contraception in South Kalimantan. There are differences in the use of modern contraception before and during the COVID-19 pandemic among NHI participants.
National Health Programs ; National Health Insurance ; COVID-19

Objectives. Within the last two decades, studies worldwide have documented catastrophic health spending and out-of-pocket expenditure in low- and middle-income countries like the Philippines. This study sought to unpack patients and their families' lived experiences in dealing with such financial challenges.

Methods. This paper stems from a multi-sited qualitative project in the Philippines involving FGDs that sought to elicit people's long-term health goals and the barriers they encounter in attaining good health. Focusing on the domain of health financing, we used principles of grounded theory to analyze how low and middle-income Filipinos pay for their health needs.

Results. For many Filipinos, health financing often necessitates various actors' participation and entails predictable and unforeseen complications throughout the illness trajectory. We describe the lived realities of health financing through four domains: 'pagtitiis' (enduring the illness), 'pangungutang' (borrowing the money), 'pagmamakaawa'  (soliciting help from the government and non-government channels), and PhilHealth--the State-owned national insurance agency--whose (non-)role figures prominently in catastrophic expenditure.

Conclusion. Our paper illustrates how illness not only leads to catastrophic expenditure; expenditure-related challenges conversely account for poorer health outcomes. By exploring the health system through qualitative means, we identify specific points of intervention that resonate across LMICs (low and middle-income countries) worldwide, such as addressing predatory loan practices and 'hidden' costs; improving public health communications; expanding government insurance benefits; and bolstering health literacy to include health financial literacy in the school and community settings.

The World Health Organization (WHO) released the global strategy report on digital health (2020-2025) in Geneva in 2019, which established the priority of the digital health strategy and formulated strategic objectives, guiding principles, action framework and implementation plans to promote the development of global digital health, and to achieve universal health coverage and the health-related sustainable development goals. Despite China's rapid development in the field of digital health, there is still a big gap between the realization of the goal of digital health. Therefore, it is urgent to grasp the major historical opportunity and step into a new era of digital health with the support of digital technology platform.
China ; Global Health ; Humans ; Universal Health Insurance ; World Health Organization

Objective. This research aimed to determine the in-patient expenditure of COVID-19 adult patient s and their out-of-pocket (OOP) payments at the University of the Philippines-Philippine General Hospital (UP-PGH) after the new PhilHealth case rate coverage was instituted last 15 April 2020. It also intended to present the preliminary data on the expenses incurred by COVID patients during the initial phase of the pandemic in the country. Methods. This study was a retrospective chart review of admitted COVID-19 patients aged 19 years old and above from 15 April to 14 August 2020 at UP-PGH that availed of PhilHealth COVID-19 case rate benefits package (C19C1-C4). Data were analyzed to extract overall expenses, out-of-pocket (OOP) charges, cost centers utilization, and other hospitalization expenditure sources. Results. Of the 691 COVID-19 patients included during the study period, 55.72% were male, mostly belonging to the 61-70 age range with a median age of 58. The average in-hospital stay was 14.20 days, and 76.99% were under charity services, with the moderate (42.84%) and mild (25.33%) pneumonia cases accounting for 68.17% of the admissions. Total hospital expenses clustered around Php51,000 to 200,000 (~USD 1,041 to 4,156), most spending between Php101,000 to 150,000 (~USD 2,078 to 3,118). The top three cost centers and expenditure sources were pharmacies, personal protective equipment (PPE) usage, and laboratory. The average OOP payment for patients less than 60 years old was higher, ranging from Php 25,899 to Php 44,428.63 (USD 538 to USD 924.44) compared to patients older than 60 (Php4,005.60 to Php 32,920.20 ~ USD 83.35 to 684.98). The most OOP charges were for the age group 19-30, amounting to Php 44,428.63 (USD 924.44). Conclusion. Preliminary findings of this study gave an actual representation of the expenses of COVID-19 patients, which can guide future utilization of the national health insurance during unexpected pandemics. Early price regulation of new therapeutic interventions, diagnostic tests, and medical supplies, e.g., PPEs, disinfectants, air filters, are measures that can be implemented.
Health Expenditures ; COVID-19 ; Insurance, Health

Pneumoconiosis, an interstitial lung disease that occurs from breathing in certain kinds of damaging dust particles, is a major occupational disease in China. Patients diagnosed with occupational pneumoconiosis can avail of free medical treatment, whereas patients without a diagnosis of occupational diseases cannot not claim free medical treatment in most provinces from the government before 2019. This study aimed to analyze the priority of medical facility selection and its influencing factors among patients with pneumoconiosis. A total of 1,037 patients with pneumoconiosis from nine provinces in China were investigated. The health service institutions most frequently selected by the patients were county-level hospitals (37.5%). The main reason for the choice was these hospitals' close distance to the patients' homes (47.3%). The factors for the choice of health care institutions were living in the eastern region (
Adult ; Aged ; China ; Female ; Hospitals ; Humans ; Insurance Coverage ; Male ; Middle Aged ; Patient Acceptance of Health Care/statistics & numerical data* ; Pneumoconiosis/therapy* ; Rural Population ; Silicosis ; Smoking

BACKGROUND: The big data provided by Health Insurance Review and Assessment (HIRA) contains data from nearly all Korean populations enrolled in the National Health Insurance Service. We aimed to identify the incidence of facial fractures and its trends in Korea using this big data from HIRA.METHODS: We used the Korean Standard Classification of Disease and Cause of Death 6, 7 for diagnosis codes. A total of 582,318 patients were included in the final analysis. All statistical analyses were performed using SAS software and SPSS software.RESULTS: The incidence of facial fractures consistently declined, from 107,695 cases in 2011 to 87,306 cases in 2016. The incidence of facial fractures was the highest in June 2011 (n = 26,423) and lowest in January 2014 (n = 10,282). Nasal bone fractures were the most common, followed by orbit and frontal sinus fractures. The percentage of nasal bone fractures declined, whereas those of orbital fractures increased from 2011 to 2016 (P < 0.001). Among orbital fractures, inferior wall fractures were the most common, followed by medial wall fractures. Among mandibular fractures, angle fractures were the most common, followed by condylar process and symphysis fractures. Although it was difficult to predict the most common type of zygomatic and maxilla fractures, their incidence consistently declined since 2011.CONCLUSION: We observed trends in facial fractures in Korea using big data including information for nearly all nations in Korea. Therefore, it is possible to predict the incidence of facial fractures. This study is meaningful in that it is the first study that investigated the incidence of facial fractures by specific type.
Cause of Death ; Classification ; Diagnosis ; Facial Bones ; Fractures, Bone ; Frontal Sinus ; Humans ; Incidence ; Insurance, Health ; Korea ; Mandibular Fractures ; Maxilla ; Nasal Bone ; National Health Programs ; Orbit ; Orbital Fractures