PhilHealth Benefit Packages: Understanding the Role of Quality Medicines and Quality Pharmaceutical Care

Transcription

1 PhilHealth Benefit Packages: Understanding the Role of Quality Medicines and Quality Pharmaceutical Care DR. FRANCISCO Z. SORIA, JR. Vice-President Quality Assurance Group

2 Outline Universal health care Definition Aquino Health Agenda National Health Insurance Program PhilHealth benefits Spectrum Drug policy- increasing access, payment mechanism Quality assurance Tsekap Role of pharmacists

3 Universal health care or universal coverage

4 Achieving Universal Health Care through the Aquino Health Agenda Three strategic thrusts: l. Financial risk protection through expansion in NHIP enrollment and benefit delivery - the population, especially the poor, will be protected from the financial impact of health care use by improving the benefit delivery ratio of NHIP; 2. Improved access to quality hospitals and health care facilities - upgrading of government-owned health care facilities will be undertaken in order to expand capacity and provide quality services to help attain MDGs, attend to traumatic injuries and other types of emergencies, and manage non-communicable diseases and their complications; and 3. Attainment of the health-related MDGs - public health programs will be focused on reducing maternal and child mortality, morbidity and mortality from TB and malaria, and the prevalence of HIV/AIDS, in addition to being prepared for emerging disease trends, and prevention and control of non-communicable diseases. 4 Source: Department of Health Administrative Order No Subject: The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos

5 Implementing the National Health Insurance Program creation of the predecessor organization (Medicare) of PhilHealth, which provided health insurance to the formal sector (public and private employees) PhilHealth was established by law, taking over from Medicare and expanding its membership to the indigent and the informal sector PhilHealth coverage= 87% of the total population benefit payments= P78 billion (2014)

6 Spectrum of PhilHealth Benefits Outpatient (PCB & MDG) Inpatient (Case Rates) Catastrophic (Z benefits) Primary Care Benefit Maternity Care Package Newborn Care Package TB-DOTS Package Animal Bite Package Malaria Package Outpatient HIV-AIDS Package Inpatient cases Day surgeries Chemotherapy Radiotherapy Hemodialysis Acute Lymphocytic Leukemia Early Breast Cancer Prostate Cancer Kidney Transplantation Coronary Artery Bypass Graft Total Correction of TOF Closure of VSD Cervical Cancer Z Morph Peritoneal Dialysis

7 Agencies Involved in Medicine Regulation Source: NCPAM presentation during Nationwide Tsekap Orientation

8 PhilHealth Reimbursement of Medicines

9 Increasing access to medicines Only drugs included in the essential drugs list (PNF) are covered. For sometime, there was a system of identifying a positive list of additional drugs after passing health technology assessment; later discontinued. Conform with Generic Act requirements (generic terminology, no brand specified)

10 Changing the way we do business with providers The challenge for PhilHealth is to increase provider efficiency in order to increase financial risk protection. This would entail changing the way we pay health care providers. Shifting to prospective payment mechanisms such as case payment, capitation and global budget may increase efficiency and promote the use of cheaper quality medicines such as generic medicines.

11 Changing the way we do business with providers Currently, medicines are bundled into the whole benefit package and paid per case (case-based payment or case rates) Case-based payment (case rates) encourages efficiency among providers including their use of medicines= low-cost quality drugs over expensive branded ones, use of only the necessary drugs discouraging polypharmacy Use of non-pnf drugs and irrational drug use can be detected during post-audit of claims and counted as violation, which may result in suspension of accreditation of health care provider (both professional and institutional)

12 Section 50 of IRR of R-A The Corporation is mandated to ensure that: a.x x x b.x x x c.acquisition and use of scarce and expensive medical technologies and equipment are consistent with actual needs and standards of medical practice and that the performance of medical procedures and the administration of drugs are appropriate, necessary and consistent with accepted standards of medical practice and ethics and respectful of the local culture. Drugs for which payments will be made shall be those included in the PNF, unless explicit exception is granted by the Corporation;

13 Section 47 of IRR of R-A (Guidelines on Claims Payment) The Corporation shall penalize health care providers for claims attended by any but not limited to the following circumstances: 1. Overutilization of services 2. Unnecessary diagnostic and therapeutic procedures and interventions; 3. Irrational medication and prescriptions; 4. xxx 5. Gross, unjustified deviations from currently accepted standards of practice and/or treatment protocols; 6. Xxx 7. Use of fake, adulterated or misbranded pharmaceuticals or unregistered drugs; 8. Use of drugs other than those recognized in the latest PNF and those for which exemptions were granted by the board;

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15 Evolution of PhilHealth s Primary Care Benefit OPB (2000) Sponsored program Gov t owned facilities Consultation Diagnostics Php 300/family/yr PCB1 (2012) SP/IP, OG/iG, OWP, DepEd Gov t owned facilities Consultation Diagnostics (+2) Medications Php 500/family/yr TSEKAP (2015) SP/IP, Senior Citizens, Kasambhay Gov t and privately owned facilities Consultation Diagnostics (+5) Medications paid to drug outlets Php 1800/family/yr

16 Criteria Used for Package Contents EPIDEMIOLOGICAL FIT COST- EFFECTIVENESS FEASIBILITY AT THE PRIMARY CARE LEVEL CAN FUND THE ENTIRE CYCLE OF CARE ALIGNMENT WITH DOH PROGRAMS AND NHIP MANDATE

17 NEW DRUGS AND MEDICINES ASTHMA Salbutamol Fluticasone Prednisone ACUTE GASTROENTERITIS ORS Zinc supplements URTI Paracetamol Amoxicillin Erythromycin PNEUMONIA Paracetamol Amoxicillin Eryhthromycin Co-amoxyclav UTI Ofloxacin Cotrimoxazole Co-amoxyclav (pregnant) DIABETES Metformin Gliclazide Aspirin DEWORMING Mebendazole NEW HYPERTENSION Hydrochlorothiazide Metoprolol Enalapril Amlodipine ISCHEMIC HEART DISEASE Aspirin Atenolol Isosorbide Mononitrate DYSLIPIDEMIA Simvastatin NEW PCB2 PCB2 PCB2

18 COST OF TSEKAP PACKAGE P800 MAXIMUM for Services & Diagnostics Capitation Paid to Tsekap Providers P 1,800 cost per family P1,000 MAXIMUM for Medicines Paid to accredited drugstores, per meds prescribed by Tsekap Providers

19 DRUG PRICE REFERENCE INDEX Ceiling price for government bidding and procurement set by DOH for all DOH facilities based on prevailing tender prices of essential medicines Used lowest winning bids Identified median procurement price (unit cost) for each molecule and strength. If less than 3 suppliers, DPR is set at lowest procured price. *Conducted by Department of Health National Center for Pharmaceutical Access and Management

20 Price Cap for Medicine Generic Dosage/Strength Form PhilHealth Name Reimbursement 1 Amlodipine 5 mg Tablet mg Tablet mg/mL 10 ml Drops mg/mL 15 ml Drops 41 2 Amoxicillin 125mg/5mL 60 ml Suspension mg/5mL 60 ml Suspension mg Capsule mg Capsule Aspirin 80mg Tablet Atenolol 100mg Tablet Co-Amoxiclav (Amoxicillin + Potassium Clavulanate) Cotrimoxazole (Sulfamethoxazole + Trimethoprim) 50mg Tablet mg + 31 mg/5ml 60 ml Suspension g Tablet mg mg/5 ml 70 ml Suspension mg mg/5ml 60 ml Suspension mg + 57 mg/5 ml 70 ml Suspension mg Tablet mg+40mg/5ml 60 ml Suspension mg + 80mg Tablet mg+80mg/5ml 60 ml Suspension mg + 160mg Tablet 1.56

21 Price Cap for Medicine Generic Dosage/Strength Form PhilHealth Name Reimbursement 10mg Tablet Enalapril 20mg Tablet mg Tablet Erythromycin 200 mg/5ml 60 ml Suspension mg Tablet Fluticasone mcg + 25 mcg x 120 Salmeterol doses Metered Dose Inhaler Gliclazide 30 mg MR Tablet mg Tablet Hydrochlorothiazide 25mg Tablet Isosorbide-5- Mononitrate 13 Mebendazole Metformin Hydrochloride Metoprolol (as Tartrate) 20 mg Tablet mg MR Tablet mg Tablet mg/5ml 30mL Suspension mg Tablet mg Tablet mg Tablet 1.42

22 Medicine Generic Name 16 Ofloxacin 17 Oral Rehydration Salts 18 Paracetamol 19 Prednisone Dosage/Strength Form Price Cap for PhilHealth Reimbursement 200 mg Tablet mg Tablet 5.71 (ORS 75-replacement) 75 Replacement 2.17 g Sachet 3.67 (ORS 75-replacement) 75 Replacement 6.1 g Sachet 6.08 (ORS 75-replacement) 75 Replacement 6.1 g 250 ml bottle mg/ml 15 ml drops mg/5ml 60 ml bottle mg/5ml 60 ml syrup mg Suppository mg Suppository mg Tablet mg Tablet mg Tablet mg Tablet 6.24

23 20 Medicine Generic Name Salbutamol (as Sulfate) + Ipratropium Bromide Salbutamol 21 Simvastatin 22 Zinc Dosage/Strength Form Price Cap for PhilHealth Reimbursement 500 mcg+2.5 mg/2ml Nebule mcg/dose x 200 doses Metered Dose Inhaler mg/ml 2.5ml Nebule mg tablet mg/ml 2.5ml Nebule mg/5ml 60 ml syrup mg tablet mg tablet mg tablet mg/ml 15 ml oral drops mg/5ml 60 ml syrup 50.05

24 Monitoring Framework Anchored in the Health Care Provider Performance Assessment System of the Corporation to evaluate the following parameters: Quality of care Access to Tsekap services Patient satisfaction Financial risk protection to members Fraud detection

25 Region Province 43 Priority Provinces # of NHTS members (Feb 2015) Total # of Mun/Cities # of Mun/Cities w/ PCB1 provider # of PCB1 providers 1 Ilocos Norte Ilocos Sur Pangasinan Cagayan Isabela Nueva Vizcaya Quirino Aurora Pampanga Zambales a Cavite Laguna Quezon Rizal

26 Region Province 43 Priority Sites # of NHTS members (Feb 2015) Total # of Mun/Cities # of Mun/Cities w/ PCB provider # of PCB1 providers 5 Camarines Sur Catanduanes Masbate Antique Iloilo Negros Occidental Bohol Cebu Eastern Samar Leyte Northern Samar Southern Leyte

27 Region Province 43 Priority Sites # of NHTS members (Feb 2015) Total # of Mun/Cities # of Mun/Cities w/ PCB provider # of PCB1 providers 9 Zamboanga del Norte Zamboanga del Sur Zamboanga Sibugay Camiguin Davao del Sur Cotabato City Saranggani CAR Abra Apayao Benguet CARAGA Agusan del Sur Dinagat Island Surigao del Norte Surigao del Sur

28 43 Priority Sites Region Province # of NHTS members (Feb 2015) Total # of Mun/Cities # of Mun/Cities w/ PCB provider # of PCB1 providers ARMM Lanao del Sur Maguindanao Sulu TOTAL

29 DOH Certify facilities as eligible to be Tsekap providers based on the standards Referral facilities for Level 2 laboratory services, Chest x-ray and ECG part of the Service Delivery Network (AO ) Certification of IT requirements: iclinicsys operational Certification of other qualified EMR providers NCPAM to supply all Tsekap drugs for areas with no partner Drug outlets

30 ENGAGING PHARMACISTS RESPONSIBLE DISPENSING PATIENT COUNSELLING MEMBER OF THE HEALTH TEAM ADVOCACY P R I M A R Y H E A L T H C A R E M O V E M E N T

31 QUALITY CONTROL Safeguarding procurement, storage and distribution of drugs RESPONSIBLE DISPENSING Dispensing medications according to doctor s prescription Ensuring proper documentation of all transactions for monitoring activities

32 MEMBER EMPOWERMENT Helping members understand the disease being treated PATIENT COUNSELLING Providing guidance on proper intake of medications including dosage and possible side-effects

33 MEMBER EMPOWERMENT Connecting the medicine prescribed with necessary lifestyle changes to ensure drug effect PATIENT COUNSELLING Develop advisories in response to common diseases in the community

34 TEAM APPROACH IN CARE Communicating and cooperating effectively with other members of the health care team MEMBER OF THE HEALTH TEAM Ensuring that the member is in the center of the therapeutic plans

35 PRIMARY HEALTH CARE Cornerstone of Universal Health Care and PNoy s Kalusugang Pangkalahatan ADVOCACY UHC cannot be achieved without responsive primary care

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