Estimating the adequacy of the Philippine Health Insurance Corporation case rate for pneumonia cases admitted at the general medicine wards of the Philippine General Hospital from January to May 2013

ABSTRACT

BACKGROUND: In 2011, PhilHealth introduced the case rate payment scheme and no balance billing policy for selected diseases which will supposedly provide financial protection to patients while promoting efficiency in hospitals. There are concerns that tertiary government hospitals might end losing money as they managed mostly complicated cases.OBJECTIVE: To estimate the adequacy of the pneumonia case rates for cases admitted in the charity Medicine wards of the Philippine General Hospital.METHODS: Costing of a random sample of ward admissions for pneumonia moderate- and high-risk from January 1 to June 30, 2013 was done. Charts were retrieved to collect data on diagnostic tests, medications and mechanical ventilator use and converted to costs using price lists. Additional costs were estimated using WHO-CHOICE values. Estimated admission cost was compared to case rates to assess adequacy.RESULTS: A sample of 113 moderate-risk and 42 high-risk pneumonia cases were reviewed. For moderate-risk pneumonia, the estimated mean admission cost was PhP26,033.82 (SD 42,987.58) with only 26.5% having costs ofPhP15,000 or lower. For high-risk pneumonia, the average was PhP33,260.65 (SD 21,865.07) with 64.4% having expenses at PhP32,000.00 or lower.CONCLUSION: The case rate of PhilHealth seems to be adequate for the cost of high-risk pneumonia but not for moderate-risk. Studies utilizing costs and for other diseases should be performed.