Philippine Health Insurance Corporation (PhilHealth) members will now have an easier time determining how much the state health insurance agency will be paying for services through the new case rate packages that pegs a specific amount for selected medical conditions and surgical procedures, effective September 1.
According to PhilHealth President and CEO Dr. Rey B. Aquino, "the shift from fee-for-service to case rates for these medical and surgical cases was prompted by developments taking place in the health care industry, most notable of which is the need to provide optimal financial risk protection especially to the most vulnerable groups, including the poorest of the poor."
He added that better member appreciation and faster reimbursement of fees to health care providers were also among the major considerations for introducing this new type of provider payment scheme.
The use of case rates is an internationally accepted payment mechanism that serves to package payment for health interventions.
Among the medical cases and the corresponding package rates are: dengue I (P8,000); dengue II (P16,000); pneumonia I (P15,000), pneumonia II (P32,000); essential hypertension (P9,000); cerebral infarction (CVA I, P28,000); cerebro-vascular accident with hemorrhage (CVA II, P38,000); acute gastroenteritis (P6,000); asthma (P9,000); typhoid fever (P14,000); and newborn care package in hospitals and lying-in clinics (P1,750).
As for the surgical procedures, it includes: radiotherapy (P3,000 per session), hemodialysis (P4,000 per session), maternity care package (MCP, P8,000) coupled with the normal spontaneous delivery (NSD) package in level 1 (P8,000) and levels 2-4 hospitals (P6,500), caesarian section (P19,000), appendectomy (P24,000), cholecystectomy (P31,000), dilatation and curettage (P11,000), thyroidectomy (P31,000), herniorrhaphy (P21,000), mastectomy (P22,000), hysterectomy (P30,000) and cataract surgery (P16,000).
Aquino said the new case rate packages are available for all member-types admitted in any of the accredited institutional health care providers nationwide. He, however, emphasized that "...for our Sponsored Program members who are admitted in government hospitals, the "No Balance Billing" (NBB) policy applies, meaning no other fees nor expenses shall be charged to or paid for by the patient-member above and beyond the package rate."
The NBB policy shall also apply to any other member type such as the employed, individually paying and overseas workers, who will avail themselves of the MCP and NCP in all accredited MCP non-hospital providers such as maternity clinics, and birthing homes.
"This policy was approved after a series of consultations with concerned medical societies and other institutional partners. These conditions and procedures were also among the top 49 percent of total claims we paid for over the previous years," the PhilHealth Chief noted.