Adequacy of PhilHealth case rate coverage for pneumonia among children under 5 years old admitted in a government hospital: Policy notes

ABSTRACT

@#Thirty-seven Filipino children die of pneumonia daily, and 90% of those who die are under 5 years old.1 More than 50% of childhood pneumonia is readily treatable with antibiotics; however, only 31% of children with pneumonia receive the antibiotics they need.2 From 2016 to 2018, pneumonia and acute lower respiratory tract infection (ALRTI) comprised the 3rd leading cause of morbidity in the Philippines across all age groups. In 2018, there were 213,611 reported cases of pneumonia and ALRTI among Filipino children <5 years old.3 In 2011, the Philippine Health Insurance Corporation (PhilHealth) created case rate packages for selected medical procedures and medical conditions, including pneumonia. A case rate is a fixed amount that PhilHealth pays to a health care provider for the diagnostic and therapeutic care of a patient with a particular disease or condition. The case rates for moderate-risk and high-risk pneumonia are PHP 15,000 and PHP 32,000, respectively.4 PhilHealth also introduced a no-balance-billing (NBB) policy, applicable to all PhilHealth Sponsored Program members and/or their dependents when they seek health care in a government hospital for diseases or conditions included in the case rate packages. The policy provides that government hospitals shall not charge other fees or expenses beyond the case rate to patients covered by the policy.4 Given the high incidence of pediatric community-acquired pneumonia (PCAP), policies that support current efforts in attaining adequate financial protection of patients--or their families--would certainly improve health outcomes related to the disease. The aim of this article is to recommend health policies based on the results of a study on health insurance coverage of patients with PCAP.