The cost of primary care: An experience analysis in an urban setting

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).

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.

Governance in primary care systems: Experiences and lessons from urban, rural, and remote settings in the Philippines

Methods@#Data on governance issues were obtained from participant observation and regular meetings facilitated over one year. Conducted across urban, rural, and remote settings, the present study outlines experience-near insights throughout a hierarchy of system implementers—from those in positions of authority to frontline workers. These insights were thematically analyzed and organized following the Health System Dynamics Framework.@*Results@#This study identified six governance challenges: 1) establishing a health information system; 2) engaging leaders, healthcare staff, and communities; 3) assuring efficient financing; 4) assuring health workforce sufficiency; 5) addressing legal challenges; and 6) planning evaluation and monitoring. To address these challenges, this study forwards systemic solutions to advance effective governance and improve healthcare performance.@*Conclusion@#A renewed approach to strengthening primary care systems is fundamental to achieving universal healthcare. This entails good governance that develops strategies, equips people with tools for proper implementation, and provides data for evidence-based policies. The experiences outlined in the present study envisions guiding policymakers toward improving health outcomes in a devolved setting.

Equity in health benefit utilization and financial risk protection in outpatient and inpatient care: Baseline survey of two socioeconomic groups of a pilot primary care benefits scheme in the catchment areas of a university-based health facility

Background@#Health inequities in the Philippines are driven by health workforce maldistribution and health system fragmentation. These can be addressed by strengthening primary care through central social health insurance (PhilHealth) coverage. However, high reported PhilHealth population coverage and health provider accreditation have not necessarily increased health benefit utilization or financial risk protection.@*Objective@#This study aims to examine the impact of an enhanced, comprehensive primary care benefits package at a university-based health facility. This paper reports baseline utilization of health services and health benefits, and out-of-pocket health spending in two socioeconomic strata of the catchment population, for outpatient and inpatient services.@*Methods@#A questionnaire-guided survey was done among randomly selected faculty (higher income group) and non-faculty (lower income group) employees to determine the frequencies and costs of using outpatient and inpatient health services, and amounts paid out-of-pocket.@*Results@#Annually, both groups had approximately 1 consultation/patient and about 15 hospitalizations per 100 families annually. For hospitalizations, non-faculty inpatients utilized health insurance more frequently than faculty inpatients (75.7% vs. 66.7%), but paid higher out-of-pocket proportions (73.3% or Php 92,479/hospitalization vs. 57.4% or Php 16,273/hospitalization). For outpatient care, health benefit utilization rates were higher among non-faculty (12.4% vs 2.1% of consultations) although low overall, with similar total (Php 2,319 vs Php 1,741) and out-of-pocket expenses (100%).@*Conclusion@#These findings confirm inequities in accessing outpatient and inpatient health services and utilizing health insurance benefits in the target population.