BACKGROUND AND OBJECTIVE

In 2018, the Philippine Congress passed the Universal Healthcare (UHC) Law and its implementing rules which mandated the enrollment of all Filipinos to PhilHealth, the national social health insurance corporation. The Department of Health (DOH) and PhilHealth will leverage their strategic purchasing power by affiliating Health Care Provider Networks (HCPNs), established within the geopolitical boundaries of a province or a highly urbanized city, through service level agreements. This study aims to shed light on what is expected from providers, payers, and regulators to implement UHC successfully.

The researchers conducted an inductive, content analytic qualitative study guided by the World Health Organization’s (WHO) Building Blocks Framework to determine the understanding and acceptance of the implementing rules of the UHC Law and the perceived barriers and enablers from the provider, payer, and regulator stakeholders in three provinces in the Philippines. Purposive sampling was utilized to provide the best representation across different economic and physical settings. A content analysis was done through an inductive process of coding concepts, which was the basis for categories grouped and matched deductively with the WHO framework. This formed the broader sub-themes and were used for the final data interpretation.

A total of 16 focus group discussions (FGDs) and nine in-depth interviews (IDIs) were performed with 84 participants. Inductive thematic analysis of categories and subcategories showed that the participants support the goals and objectives of the UHC Law. Still, perceived barriers refer to the lack of and improper use of funds, the need to clarify the implementing guidelines, and the role of politics. The participants indicated that solidarity and social connectedness with health system adaptability and resilience are enablers for the success of UHC reforms.

Proposals to mitigate the barriers include expanding the funding source, clarifying rules on the f inancial management system, and providing guidelines on health delivery integration to ensure access to patient care. Decentralization with autonomy will allow the stakeholders to align health programs with local needs. Proper representation in decision-making bodies is desirable to establish strong community involvement and solidarity. Resilience and adaptability based on a feedback loop are imperative.

Objectives: PhilHealth’s present health benefit scheme is largely centered on in-patient services. This inadvertently incentivizes hospital admissions for increased access to benefit coverage. To address this problem, this study proposes a costing method to comprehensively finance outpatient care. The objective of this paper is to estimate an annual primary care benefit package (PCBP) cost based on experience analysis (actual benefit usage) on the first year of implementation at an urban pilot site. Methods: A cost analysis was conducted to assess a disease-agnostic primary care benefit package for an urban outpatient government facility over the first year of implementation. Costing information was gathered through staff interviews, accounting documents, and usage data from the electronic health records system available on-site. Results: The annual primary care cost was defined as the estimated financial coverage for eligible employees and their eligible dependents (n=15,051). The annual utilization rate for consultations was reported at 51%. Of patients who consulted, approximately 38% accessed free available diagnostic procedures and 48% availed of free available medicines. Based on these usage rates, the annual primary care cost for the first year was computed at PhP 403.22 per capita. Conclusion Our study shows that on the first year of coverage in a government run urban outpatient facility, an allocation of PhP 403.22 per capita can allow coverage for a disease-agnostic package (comprehensive); this amount excludes out-of-pocket expenses incurred by the target population of this study. This amount is feasible only when coopted with opportunistic registration, reduction of untargeted check-ups, prior contextual community engagement, and streamlining of patient-transactions through an electronic health record (EHR).
Healthcare Financing ; Costs and Cost Analysis ; Primary Health Care

OBJECTIVES

PhilHealth’s present health benefit scheme is largely centered on in-patient services. This inadvertently incentivizes hospital admissions for increased access to benefit coverage. To address this problem, this study proposes a costing method to comprehensively finance outpatient care. The objective of this paper is to estimate an annual primary care benefit package (PCBP) cost based on experience analysis (actual benefit usage) on the first year of implementation at an urban pilot site.

A cost analysis was conducted to assess a disease-agnostic primary care benefit package for an urban outpatient government facility over the first year of implementation. Costing information was gathered through staff interviews, accounting documents, and usage data from the electronic health records system available on-site.

The annual primary care cost was defined as the estimated financial coverage for eligible employees and their eligible dependents (n=15,051). The annual utilization rate for consultations was reported at 51%. Of patients who consulted, approximately 38% accessed free available diagnostic procedures and 48% availed of free available medicines. Based on these usage rates, the annual primary care cost for the first year was computed at PhP 403.22 per capita.

Our study shows that on the first year of coverage in a government run urban outpatient facility, an allocation of PhP 403.22 per capita can allow coverage for a disease-agnostic package (comprehensive); this amount excludes out-of-pocket expenses incurred by the target population of this study. This amount is feasible only when coopted with opportunistic registration, reduction of untargeted check-ups, prior contextual community engagement, and streamlining of patient-transactions through an electronic health record (EHR).

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.

Background: The enactment of the Universal Health Care Act is anticipated to bring wider coverage and accessibility of quality healthcare services as stipulated in its objectives. With the integration of the healthcare system at the provincial level, determining population- and individual-based services is crucial in mapping the managerial and financial roles. Hence, this study aimed to establish the criteria for identifying population-based and individualbased health services in the Philippines. Methods: A systematic review of literature was conducted to generate evidence for the policy brief and discussion points on the roundtable discussion spearheaded by the UP Manila Health Policy Development Hub in collaboration with the Department of Health. Key stakeholders of the policy issue convened to share expertise and insights in determining criteria for population- and individual-based services, intending to generate consensus policy recommendations. Results: The general scope of individual-based health services stipulated in the Law are to be financed under the benefit packages of PHIC and HMOs. Meanwhile, population-based services are those that address public health issues such as health promotion and disease surveillance. Several services considered as ‘grey areas’ are those that fall in the overlap of the individual- and population-based services. These services may be examined through an outcome-based algorithm that examines fragmentation issues both in the supply and demand side of service delivery. Conclusion and Recommendation Proposed criteria in identifying individual- and population-based services include the number of recipient/s, the effectivity of service delivery and utilization, and source of funding. Health programs that are in the grey areas can be examined through an outcome-based algorithm.
Healthcare Financing ; Health Services Accessibility

Objectives: The health financing scheme brought by the Universal Health Care Act has a significant change in the landscape of allocating funds for health services, as well as in the delineation of roles among the key actors. Consistent with the law, the protection from the health financial risks of Filipinos must be guaranteed. This study aimed to determine the roles of the government and other key agencies in financing population-based and individual-based health services in the Philippines. Methods: A systematic review of literature was done to generate evidence for the policy brief and proposed policy alternatives. The UP Manila Health Policy Development Hub organized a roundtable discussion in collaboration with the Department of Health participated by key stakeholders from various sectors involved in the policy issue. Systematic review and insights from the discussion were analyzed to produce consensus policy recommendations. Results: Given the current procurement and financing, the DOH should fund population-based services while PhilHealth, with the assistance of Health Maintenance Organizations (HMO) for premium holders, should fund individual-based services. Health programs with grey areas (i.e. with both individual- and population-based service) need further technical discussions. It is imperative to have clear-cut specific guidelines on the managerial and financial roles of the provincial health board and the scope of financing service delivery. Conclusion Delineating the roles of DOH, PhilHealth, and HMOs in financing health services is not without risks. The utilization of the special health fund at the provincial level should be carefully implemented and monitored to minimize inefficiencies and fraud.
Healthcare Financing ; Universal Health Insurance ; Insurance, Health

Background: The Universal Health Care Law seeks to optimize financing of personnel costs without compromising quality and equitable health care among the health care facilities. This position statement aimed to identify strategies and policy recommendations for the cost-effective financing of health personnel in public healthcare facilities. Methods: A systematic review of literature was done to generate policy brief and key points for roundtable discussion in collaboration with the Department of Health (DOH). The discussion was guided by the three health financing options of DOH: (a) retain Personnel Services (PS) as DOH budget but shift Maintenance and Other Operating Expenses (MOOE) to PhilHealth; (b) shift PS and MOOE to PhilHealth, and (c) rationalize part-time status in government hospitals. Results: The pros and cons of financing options were cross-examined. In Option 1, physicians in government hospitals would receive fixed salaries from DOH / Local Government Units. In Option 2, there would be a monopsony between PhilHealth and provincial power. Payment will be performance-driven, and balance billing will be eliminated. Option 3 would be a set up of retaining part-time positions for physicians. Conclusion and Recommendation Participants deduced that for Option 1, provision of salary augmentation sources and ensuring adequate plantilla items and level of remuneration in government hospitals should be considered, in order to sufficiently compete with physicians’ income from private practice. For Option 2, the PhilHealth reimbursement system should ensure timely reimbursement so as not to subject care providers to financial instabilities. For Option 3, rationalizing part-time status should be flexible and can be applied regardless of how physicians are paid, as this would incentivize caregivers to work harder and smarter.
Universal Health Insurance ; Healthcare Financing ; Physicians ; Universal Health Care ; Reimbursement Mechanisms

Objective: The objectives of this paper were to describe and analyze the utilization of the Department of Health-Medical Assistance Program (DOH-MAP) at the University of the Philippines-Philippine General Hospital (UP-PGH) in order to provide actual data on its implementation and to give recommendations on future enforcement. Methods: Clinical and fiscal records of DOH-MAP recipients were prospectively tracked and analyzed from January to June 2018. Results: A total of Php 20,875,291.98 was utilized in the program from January to June 2018. The departments of Medicine (29.68%), Surgery (26.25%), and Neurosciences (15.99%) were identified as the clinical departments with the highest allocation of assistance fund. The pharmacy (64.28%), laboratory (12.87%), and outsourced medical equipment and services from EQUILIFE (10.26%) were determined to be the cost centers with the highest allotment. Conclusion The clinical departments and cost centers with high funding utilization identified in this study are recommended to be given appropriate increase in budget allocation, equipment procurement, maintenance and enhancement, and service improvement in order to provide a comprehensive health service delivery for patients of UP-PGH.
Health Expenditures ; Healthcare Financing ; Medical Assistance

A primary mission of the Korean pancreatobiliary association (KPBA) is to promote high quality patient care and safety in the field of pancreatobiliary diseases. Among these, endoscopic retrograde cholangiopancreatography (ERCP) is one of the most important procedure among various endoscopic procedures. The purpose of this document is to provide a current Korean medical detailed and departmental specialty system that should be considered before preparing of privileging and credentialing for ERCP subspecialty and making suitable framework for determining the competency of practicing endoscopists and for the granting of privileges to perform ERCP. As such, this document provides current situation of Korean medical specialty and subspecialty system to assist KPBA in making credentialing organizations especially for ERCP subspecialty.
Cholangiopancreatography, Endoscopic Retrograde ; Credentialing ; Financing, Organized ; Patient Care

Academic medicine is built from a foundation of education, research, and patient care. Since good patient care results from the application of medical research and continuous education, these three components cannot be separated for medical development to occur. In Korea, many obstacles hinder the achievement of academic medicine, such as an inefficient medical delivery system, limitations of primary care, low insurance prices, and no long-term health care plan. Medical education has changed to outcome-based education, but presented temporal integration status. Governance of healthcare research is not centralized, and Korea is awarded relatively fewer grants than other countries. Medical professors have reached a burnout state due to patient care responsibilities in addition to research and education duties. Many medical systems, including the medical delivery system and insurance problems, may contribute to distrust between doctors and patients. The government is not involved in a long-term health care policy. The multitude of factors mentioned here are hindering the achievement of academic medicine in Korea.
Awards and Prizes ; Delivery of Health Care ; Education ; Education, Medical ; Financing, Organized ; Health Services Research ; Humans ; Insurance ; Korea ; Patient Care ; Primary Health Care