The PhilHealth is a Government Owned and Controlled Corp. (GOCC) created through the National Health Insurance (NHI) Act of 1995 or Republic Act 7875. It is the administrator of the National Health Insurance Program (NHIP) which was established to provide health insurance coverage for all Filipinos and ensure affordable, acceptable, available, and accessible healthcare services for all citizens of the Philippines.
In 2019, The Universal Health Care Law through republic Act 11223 was enacted. Universal Health coverage ensures that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full rage of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. Under the Universal Health Care Law, contributions shall be financed either through social health insurance contributions or through government subsidies legislated each year under the General Appropriations Act. The former are sourced from the contributions of Direct Contributors comprised of the employed (including household help), self-earning individuals, professional practitioners and Overseas Filipino Workers; while the latter is made possible for the Indirect Contributors comprised of indigents, senior citizens, PWD (persons with disability) among others.
The Universal Health Care Act aims to provide all Filipinos with equitable access to quality and affordable healthcare services without causing financial hardship.
In November 2022, President Ferdinand R. Marcos, Jr. named Emmanuel R. Ledesma Jr., a finance expert, as PhilHealth’s Acting President and Chief Executive Officer (PCEO). In July 2023, eight months later, Pres. Marcos formally appointed Ledesma as PCEO of the state insurer.
Prior to his stint in PhilHealth, PCEO Ledesma has a vast experience in the banking and corporate finance sector. He worked for various local and international banks which include Philippine Commercial International Bank, Royal Bank of Canada and PCI Capital Corporation. He also had extensive experience in wealth management after having served as Director/Vice President of Morgan Stanley and Co., Inc. Private Wealth Management Group for 12 years.
Aside from his solid background in finance, he was into power and energy consulting prior to rejoining the government sector. He was also President and CEO of Power Sector and Liabilities Management Corporation for 5 years.
PCEO Ledesma took the helm of Philhealth, he has been consistently pursuing the following programs, as his agenda, anchored on the objective of Pre. Marcos Jr. administration with regards to health care. His program priorities are:
- Access to Health Care Services
As Pres. Marcos Jr. emphasized that, bring medical services closer to the people and wait for them to come to the hospitals or travel to the capital of any local government unit for them to avail of health services because the government will increase capacity to provide services. In response, Philhealth improved its accreditation activities and enhanced its primary care benefits to ensure that every Filipino, even those in far-flung areas, will be able to avail of medical services without traveling to another Local Government Unit.
As June of 2023, Philhealth has total of 10,870 accredited facilities nationwide, 58% of which are government facilities while the remaining 425 are private institutions. The list of healthcare facilities accredited by Phlhelth includes
- Hospital
- Infirmaries/Dispensaries
- Animal Bites Center
- Ambulatory Surgical Clinis
- Drug Rehabilitation Centers
- Free-Standing Dialysis Clinics
- Family Planning Providers
- Konsulta Providers
- Maternity Care Package Providers
- Outpatient MHIV/AIDS Centers
- Outpatient Malaria Providers
- TB-DOT Providers
- Covid-19 Testing Laboratories
- Covid-19 Community Isolation Units
- Covid-19 Home Isolation Benefits Package
- Enhanced Primary Care Benefit: The PhilHealth Konsulta Package
Through the UHC Act, the Corporation has released its enhanced primary care benefits package as PhilHealth Konsultasyong Sulit at Tama or PhilHealth Konsulta. It aims to provide all Filipinos access to a primary care provider that shall deliver basic essential services at every life stage to promote health, identify risks, and ensure early diagnosis, treatments, and care. The Konsulta package provides access to primary care services such as chest X-rays, fasting blood sugar and electrocardiogram (ECG), among others. Additionally, drugs and medicines for certain medical condition such asthma, diabetes, and hypertension will be dispensed through Konsulta provider for free.
As of November 30, 2023, PhilHealth has 2,509 accredited Konsulta provider all over the country. In terms of registration, as of October 2023, Philhealth has already registered 18,625,002 beneficiaries against its target of 18,413,824 for CY 2023. To further the package, PhilHealth is joining the Lab for All Caravan.
PhilHealth also started working on the implementation of the Primary Cared Provider Network (PCPN). PCPN is a network of providers whether public, private, or mixed established to deliver Konsulta services in a coordinated and integrated manner. The department of Health (D0H), Department of Interior and Local Government (DILG), and PhilHealth, through the local health system integration, have a pilot implementation of network contracting of the PhilHealth Konsulta Program in 5 public PCPNs. The Pilot sites include Bataan, Guimaras, Quezon, South Cotabato, and Baguio City. PhilHealth also started handling the initial frontload capitation to South Cotabato, Quezon, Bataan and Baguio City. PhilHealth also integrates its primary care package, the PhilHealth Konsulta with select SDG-related benefits packages, namely the Tuberculosis, Animal Bite, HIV-AIDS and Malaria packages to provide a more comprehensive set of health services to be made available through the primary care facilities.
Further, PhilHealth is set to launch the PhilHealth GAMOT. It is a standalone outpatient drug benefits designed to provide coverage for essential medicines. The benefit serves as the pharmaceutical service delivery arm of the PhilHealth Konsulta in the setting of healthcare provider network.
- Benefit Expansion
- Institutionalizing the 156 Hemodialysis Session
PhilHealth increased the number of covered Hemodialysis (HD) sessions. The session increased from 90 to 144 during the pandemic. However, recognizing the needs of affected members, PhilHealth is again increasing the covered session to 156 from 144.
The expanded benefits package would certainly help many Filipinos especially as HD is the top procedure claimed in 2022 in terms of count (3.6M claims totaling to P17.34B) and has consistently been one of the most availed benefit package of the Corporation.
- Increase in package rates of Pneumonia and Acute Stroke.
PhilHealth also expanded three case rate packages from the top 10 paid medical cases (in terms of claims count). PhilHealth already released the Circulars for these benefit packages.
- High-Risk Pnuemonia (from P32,000 to P90, 100, a 182% increase)
- Acute Stroke, Ischemic (from P28,000 to P76,000 a 171% Increase) and
- Acute Store, Hemorrhagic *from P38,000 to P80,000 a 111% increase).
- Outpatient Mental Health Package
This comprehensive mental health support is offered in two packages:
- General mental Health services packages amount to P9,000.00
- Specialty Mental Health service packages amount to P16,000
Per person annually. Individuals must be 10 years and older to be eligible for psychiatric services while no age restriction for those in need of neurological services. PhilHealth urges healthcare facilities to apply for accreditation so that they will able to provide these benefits to Filipino who need this treatment.
- Adjustment of case rate in 2024
PhilHealth is also set adjust the rates of most of its benefit packages starting in 2024, which result in increased financial coverage for Filipinos’ hospitalization expenses.
The adjustment is prompted by the increasing costs of healthcare in the country brought about by inflation. The case rates are likely to increase to a maximum of 30% across all cases. This is to expected to lower out-of-pocket expenses of patients during hospitalization and in the availment of Philhealth benefits for outpatient care.
- More expansions in the pipeline
PhilHealth also intends to release more benefits such as outpatient therapeutic care for severe acute malnutrition and the enhancement of Z benefits packages such as breast cancer, prostate cancer, cervical cancer and open-heart surgery for children.
PhilHealth initially adjusted the rates of its Z Benefits for Selected Orthopedic Implants in June 2032.
- Strengthened Partnership
Ledesma Administration strongly believes in strong partnership. It is through the valuable support of its key stakeholders and advocates that Philhealth can easily achieve its goals.
PhilHealth consistently taps relevant groups, organizations and development partners to help PhilHealth deliver its mandate to the Filipino people.
Some of the development partners that PhilHealth has ongoing engagement are the Asian Development Bank (ADB), United Nation Children’s Fund (UNICEF), The Unite State Agency for International Development (USAID), the World Bank (WB), the World Health Organization (WHO), ThinkWell Philippines, Inc. They provide technical assistance (TA) to PhilHealth in the form of sharing of information and expertise, instructions, skills training, transmission of knowledge and consulting services.
On the other hand, local partners such as the MMDA, PPA, MRT, LRTA, OTC, Caritas Manila and MIAA, support PhilHealth in its social marketing and advocacy efforts. Others local partners such as UP Manila and Phil. Institute for Development Studies support the capacity building of the PhilHealth workforce and its research for evidence-informed decision making
- Good Governance
Continuous improvement of PhilHealth’s processes is another priority of PCEO Ledesma. He strongly supports initiatives that will promote good governance to ensure that members and stakeholders will receive only the best from PhilHealth.
In October 2023, Philhealth received the Certificate of Recognition from the Civil Service for completing all the requirements tom achieve Maturity Level 2 of the Enhance Program to Institutionalized
- UHC Goals
- All Filipinos Covered
With the signing of the UHC, all Filipinos are automatically covered under the NHIP – ensuring PhilHealth’s coverage rate at 100%. In 2021, the country’s projected population was at 110,198,654. This increased to 111,572,254 Filipinos in 2022. In 2023, this again increased and is now at 112,892,781. As such, because of UHC close to 113M Filipinos are assured of immediate access to PhilHealth’s benefit package.
For purposes of ensuring the enrolment of all Filipinos in the PhilHealth Database, the Corporation also regularly monitors the Registration Rate to the NHIP. PhilHealth Beneficiaries are referred to members plus their respective qualified dependents. As of June 2023, PhilHealth registered 104M, or 92% of Filipinos out of the PSA’s projected population of 112M Filipinos for 2023
- Sustaining the Program: Premium Collections
The deferment of the scheduled premium increases in 2022 and 2023 has adverse effect on PhilHealth’s collection effort even potentially impending timelines of the UHC. Regardless, the Corporation shall march on and continue to innovate with its programs as increased and sustainable collections are necessary to ensure funding of the many benefits PhilHealth intend to roll out.
Despite the deferment of the scheduled premium increase per the UHC Act, PhilHealth was still able to collect P216.78B in 2022, a 16% increase from the 2021 collection at P186.22B.
- Benefit Expenses
With the increase in coverage, benefit expense have also increased over the years. In 2021, PhilHealth released P140.16B for CY2022, PhilHealth’s claims expenses increased by 2.4% at P143.56B, equivalent to almost p2.8B per week.
As of June 2023, PhilHealth paid a total of P59.16B to almost 6B claims. In terms of Claims Count, hospitals comprise 84% of all paid claims by PhilHealth.
- Prompt Claims Processing
PhilHealth remains steadfast in its commitment to pay hospital claims that are in order and complaint with rules and regulations. As the national purchaser of health services, PhilHealth is expected to pay the benefit claims of health care provider based on diagnosis and performance.
PhilHealth only recognizes “good claims” as its payables pursuant to prevailing government accounting rules and regulations. In addition, PhilHealth is also mandated to process claims within 60 days per Section 47, Letter I of the Revised Implementing Rules and Regulations (IRR) of the National Health Insurance Act of 2013 (RA7875 as amended by RA9241 and 10606). This is to give the Corporation ample time to review the claims for completeness and more importantly for fraud.
As of June 2023, the average Turn-Around-Time (TYAT) for Claims Received/Re-filed and Paid is at 27 days, which is 33 days faster than the 60 days prescribed by law.
- Information Technology (IT) Enhancements
PhilHealth is currently in collaboration with the Department of Information and Communications Technology (DICT) to improve a number of its services: Enhance of members’ online access to membership and contribution records; integration of PhilHealth’s services with the DICT’s eGov Super App; and enhance member portal access, among others.
- Shifting provider-payment Mechanisms (FFS to Case Rates to DRGs)
The adaptation of the Fee-for-Service (FFS) Provider Payment Mechanism (PPM) has intrinsic constraints that limit the Corporation from fully realizing the intents of some of the guiding principles in RA7875 as amended such as University, Equity and Cost Containment among others.
In alignment with the goal of the UHC Act (Section 18.b) PhilHealth has already begun work on adopting performance-driven, close-end, prospective payments based on disease or diagnosis-related groupings and validated costing methodologies. Diagnosis-Related Groups or DRGs are based on a broader set of components for determining clinics and economic costs of care.
Through DRGs, payments are more responsive to inpatient cares’ complexities and improve providers’ efficiency by linking clinical standards and resource needs. PhilHealth projects that the shift would therefore reduce Out-of-Pocket (OOP) expenses of patients. Ultimately, this allows PhilHealth to take on a more substantial strategic purchasing role and incentivize optimal health outcomes with more rationalized resources and expenditures. DRG implementation is targeted to commence in 2024.
Zero Co-payment: One of the premier programs of the Corporation before the UHC Act is the No-Balance Billing (NBB) program wherein the marginalized sectors (e.g. Indigents, Senior Citizens, etc.) enjoy zero co-payment or zero out-of-pocket expenses during hospitalization.
NBB means no other fees or expenses shall be charges to or paid for by the patient-member above and beyond PhilHealth’s package rate (in government facilities). With the transition to the new provider-payment mechanism as explained earlier (DRGs), PhilHealth will also soon transition to the “No Copay” and “Fixed Copay” programs. This is essentially a step up from the NBB initiative as not only will it cover all member categories, but support value is also expected to be higher.
In the “No Copay” program there will be zero out-of-pocket expenses for members availing of benefits. AS for “Fixed copay”, initial discussions point to providing members options by paying a fixed amount to supplement PhilHealth’s benefits package – instead of the varying costs/expenses presently charged by health care facilities, among others. This shall empower members by setting more predictable healthcare costs compared to the present case rate system.
To gauge where Support Value (SV) is in the UHC era, PhilHealth is currently studying through a third-party provider, the support provided to members.
In a span of barely one year when PCEO Ledesma took the challenge to lead PhilHealth, and able to accomplish all of these. His vison is clear – to realize what the government wants for the people, to provide financial risk protection in times of medical needs through their PhilHealth.
Given all the reforms and benefits expansion to PhilHealth, PCEO Ledesma aims to surpass his performance in 2023.
