chapter 6 uhc

Financing Health Services

UHC Act Overview

  • The UHC Act establishes financial mechanisms for equitable access to quality healthcare for all Filipinos, ensuring protection against financial risk.

Special Health Fund (SHF)

  • Establishment of SHF: A repository for all healthcare financial resources pooled and managed by Province-wide or City-wide Health Systems (P/CWHS).

    • Sources of SHF:

      • Financial grants/subsidies from the national government (DOH).

      • Income from PhilHealth payments.

      • Donations and grants from local/international partners.

      • Local health budgets from Local Government Units (LGUs).

PhilHealth Payment System

  • Global Budget Scheme: Transition to a payment mechanism where a fixed amount covers aggregate service delivery, allowing flexibility in spending.

    • Based on diagnosis related groups (DRGs) for hospital services and capitation for outpatient primary care.

  • No Co-payment Scheme: Extends coverage to all PhilHealth members, unlike the previous No Balance Billing scheme covering selective categories.

    • No Balance Billing applies to:

      • Indigent members.

      • Sponsored members.

      • Senior citizens.

      • Kasambahay (household workers).

      • Lifetime members.

    • Eligibility for No Co-payment is based on accommodations during confinement.

Health Financing Functions

Core Functions

  • Revenue Generation: Collecting funds to ensure sufficient purchasing power for health services.

    • Sources include premiums from direct contributors and subsidies from government, sin taxes, and the national government’s share from gaming and charity foundations.

  • Pooling of Funds: Compiling resources within PhilHealth for broader service coverage, irrespective of socioeconomic status.

    • Combining national and local budgetary resources for comprehensive health services.

  • Purchasing of Services: Ensuring strategic utilization of resources for effective health outcomes at reasonable costs.

Special Health Fund Management

  • Creation and Management:

    • The SHF is created under the UHC Act to integrate local health financing.

    • Guidelines for SHF management are jointly issued by various government departments, ensuring strategic resource allocation and monitoring.

    • Types of LGU Funds:

      • General fund: Used for unspecified local government purposes.

      • Special fund: Used for specific local government goals, including the SHF for integrated healthcare.

Uses of the Special Health Fund

  • Funding is directed towards:

    • Population-based health services (e.g., epidemiological services, health promotion).

    • Individual-based health services (e.g., inpatient care, laboratory tests).

    • Health system operating costs and capital investments for health infrastructure.

    • Remuneration and incentives for health workers.

Provider Payment Mechanisms

Mechanisms Summary

  • Global Budget: A prospective payment covering aggregate provider spend for set services, to be initially available to public providers.

  • Diagnosis-Related Groups (DRGs): A classification system for hospital cases ensuring tailored payments based on clinical similarities and expected resource usage.

  • Capitation: Fixed payment per individual or group for primary care services, with incentivization for savings.

Transition of Payment Methods

  • Shift from fee-for-service to DRGs and capitation to enhance efficiency and care quality in health service delivery.

Cost-sharing Mechanisms

Overview

  • Cost-sharing includes patient payments upon receiving health services (co-payment and co-insurance).

    • Co-payment: Flat fee at the point of service.

    • Co-insurance: Percentage of medical charges covered by the insured.

    • Strategies implemented under the UHC Act include:

      • No co-payment for basic accommodations.

      • Co-payment and co-insurance regulated by DOH and PhilHealth for non-basic accommodations.

Compliance

  • Healthcare facilities must comply with bed ratio requirements to ensure adequate basic accommodations, impacting PhilHealth's accreditation process.