Health benefit utilization and out-of-pocket expenses in outpatient care and hospitalizations: Baseline surveys of three primary care sites in the Philippines

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.@*Objective@#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.@*Methods@#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. @*Results@#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). @*Conclusions@#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.

Mental health and well-being of PhilHealth frontline workers

Background@#The mental health and well-being of PhilHealth frontline workers were investigated to inform decision-makers and organizations in developing policies and programs to promote welfare of employees, thereby subsequently improving productivity and service delivery. @*Objectives@#The study aimed to describe the demographic profile of participants and their level of mental health and well-being as well as to determine if a significant relationship exists between the said variables. @*Methodology@#This is descriptive research that gathered respondents’ socio-demographic data. The target population was PhilHealth frontline workers all over the Philippines. Two existing self-report scales were used to measure the mental health and well-being of respondents. Statistical tools were then used to interpret data. @*Results@#The majority of demographic factors were related to mild anxiety levels. The mean scores suggest that ages 20-29 are more anxious than those aged 50 and above. Other findings noted that the position title of Administrative Aide III and place of assignment in PhilHealth Regional Office II and XII showed a severe level of anxiety. Mean scores also showed mild anxiety as the length of years working in the corporation increased. In conclusion, age, years in service and place of assignment have a significant negative impact on participants’ mental health. @*Conclusion@#In conclusion, age, years in service and the place of assignment were the variables found to have a statistically recognizable impact on mental health and well-being of PhilHealth frontline workers. These findings were considered in proposing Mental Health Programs for PhilHealth employees. @*@#

Hospitalization expenditure of COVID-19 patients at the University of the Philippines-Philippine General Hospital (UP-PGH) with PhilHealth coverage

@#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.

Direct cost of hospitalization of pediatric focal epilepsy patients in a tertiary medical center

OBJECTIVES@#To determine the cost of hospitalization, percentage distribution of expenses, and average expenditures covered by PhilHealth, hospital share and patient’s share in financing the hospitalization of pediatric focal epilepsy patients in a tertiary government hospital.@*METHODOLOGY@#This is descriptive retrospective research of patients diagnosed and managed as focal epilepsy from July to December 2018. Mean, standard deviation and percentage distribution of expenses were determined.@*RESULTS@#The mean cost of hospitalization is 21,545.96 Php and the laboratory cost contributes the most to the total cost with a mean of 6,046.08 Php. The mean cost shouldered by PhilHealth is 3,734.26 Php which is 17.33% of the total cost of hospitalization.@*CONCLUSION@#The laboratory cost makes up most of the hospital cost. Philhealth covers a small percentage of the hospitalization cost of pediatric focal epilepsy patients with most of the total cost shortly followed by the patient’s share.

Factors affecting delays in PhilHealth electronic claims reimbursement among hospitals: An initial study

Background@#In the continuity of care, family and community physicians take into consideration patient insurance coverage, especially for those who require higher levels of care. The Philippine Health Insurance Corporation (PhilHealth) has had its electronic reimbursement claims processing since 2011 but the utilization of this system by hospitals may be affected by delays in claims reimbursement. Factors associated with such delays warrant further investigation.@*Objectives@#This study aimed to determine the perceived factors by concerned hospital staff that affect delays in PhilHealth’s electronic claims processing system.@*Methods@#Three focus group discussions (FGDs) were conducted using a predetermined set of questions. The hospitals were selected from respondents of a survey of a bigger study on the applicability of PhilHealth’s electronic claims processing. Each FGD involved eight-to-ten participants, mostly PhilHealth officers or information technology personnel from different hospitals covering Luzon, Visayas, and Mindanao. The hospitals were of different types/levels and included both government-run and privately-owned.@*Results@#Factors affecting delays in electronic claims reimbursement are intrinsic to the hospitals’ operations, with delays in obtaining the physician’s signature as the most common cause. Accessing PhilHealth’s server was another major factor and was aggravated by problems in clarifying patient eligibility, non-updated data, and variations in the emphasis of regional evaluators. Hospitals within the national capital region and those using their own electronic medical records and health information system had better experiences with the electronic claims reimbursement.@*Conclusions@#The main factors affecting delays in electronic claims reimbursement among hospitals are associated with the hospitals’ institutional processes. The active participation of family physicians and primary care providers can help address these issues and subsequently improve service delivery, PhilHealth utilization, and overall patient satisfaction.

Factors associated with utilization of primary preventive services of Tamang Serbisyo para sa Kalusugan ng Pamilya (TSeKaP) among PhilHealth indigent members in Manila

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> The primary preventive services of TSeKaP promote disease prevention among marginalized groups. The threat of non-utilization, however, undermines the effective implementation of the program. To fill in the knowledge gap regarding utilization of primary preventive services, rate of utilization and factors associated with utilization of primary preventive services must be determined.</p><p style="text-align: justify;"><strong>OBJECTIVE:</strong> To determine the rate of utilization and the association of selected factors with utilization of primary preventive services of TSeKaP among PhilHealth Indigent Member of Manila.</p><p style="text-align: justify;"><strong>METHODS:</strong> Using a two-stage cluster sampling, 145 PhilHealth Indigent Members were randomly selected and interviewed. Chi-square test and Fisher's exact test were used to determine associations. FGDs were also conducted to gather reasons related to utilization.</p><p style="text-align: justify;"><strong>RESULTS AND CONCLUSION:</strong> Among those surveyed, 68.28% were found to have utilized at least one primary preventive service. Age (p-value=0.021), knowledge (p-value=0.015), familiarity (p-value=0.029), and accessibility (p-value=0.013) were found to be associated with utilization. Utilization generally increases as the age group increases. Those with satisfactory knowledge on TSeKaP, those familiar with their health center, and those who report that their health center is accessible were 1.45 times, 2.12 times and 2.83 times more likely to utilize than their counterparts, respectively. Results showing a significant proportion of non-utilization emphasize the need to improve implementation strategies by improving not only the knowledge of respondents' on TSeKaP but also their familiarity with their health centers. The use of various communication channels, such as barangay bulletin, public address system, radio or television, may aid the dissemination of pertinent information regarding the program as perceived by the respondents.</p>

Validation of the selection process of PhilHealth sponsored members in 4 barangays in a municipality in Batangas using the participatory action research

OBJECTIVE: The present study aims to correlate the LGU list of PhilHealth Sponsored Members in a municipality of Batangas with the list of poor residents as identified by the Participatory Action Research (PAR) methodology. METHOD: Interview of key informants documented the processes utilized by the LGU in determining PhilHealth beneficiaries for the Sponsored Program and the Participatory Action Research (PAR) survey in the classification of households into poor, middle and rich in four barangays of the municipality. The list of LGU Sponsored members was then cross matched with the PAR household classification. RESULTS:The comparison of the LGU list of Sponsored members and the household classification by the PAR survey showed a wide discrepancy: (1) 464 "Not Found" Sponsored households or 70% of the LGU's Sponsored list; (2) inclusion of the non-poor: 140 middle class families as classified by the PAR survey or 21.1% of the LGU's Sponsored list; and (3) exclusion of 413 or 87.5% of true poor families identified by the PAR Survey. Only 59 families or 8.9% of the LGU Sponsored list were classified as poor families by PAR. CONCLUSION:PAR offers communities, LGUs and the National Health Insurance Program a tool to validate the coverage of the Sponsored program. LGUs and the PhilHealth should consider such tool or similar tools to validate their identification, selection and enrollment of the poor, which is extremely vital in achieving universal coverage. Given the right tool, communities are in the best position to identify the poor for the Sponsored program. By way of collaboration with the underprivileged themselves, the academe has a role in assisting communities in acquiring collective awareness of their own situation and developing capacity for improving their lives. The academe also has a role in assisting LGUs in improving their health systems and national health programs in validating and improving their implementation. Further studies should be done to investigate the following: the identity of the "not found" SP members; the utilization of PhilHealth benefits by the poor; and the prospect of utilizing the PAR method by other non-academic institutions in monitoring the progress of community programs.