chapter 6 uhc

Page 1: Financing Health Services

Overview of UHC Act

  • The Universal Health Care (UHC) Act mandates financial mechanisms for healthcare access in the Philippines.

Special Health Fund (SHF)

  • A repository for pooled financial resources in the Province-wide or City-wide Health Systems (P/CWHS).

  • Sources include:

    • National government grants and subsidies (DOH).

    • PhilHealth income.

    • Local health budgets pooled by LGUs (Local Government Units).

PhilHealth’s Global Budget Scheme

  • PhilHealth transitions to a global budget scheme.

  • Fixed allocations cover predetermined services, offering flexible spending.

Page 2: No Co-payment Scheme

No Co-payment vs. No Balance Billing

  • The No Co-payment scheme applies to all PhilHealth members and dependents.

  • No balance billing covers specific categories (indigent, sponsored, kasambahay, senior citizens, lifetime members).

  • Eligibility is based on membership for No Balance Billing, while No Co-payment hinges on accommodation type during hospitalization.

Page 3: Health Financing Functions

Core Functions

  1. Revenue Generation

    • PhilHealth needs sufficient revenue for purchasing health services.

    • Collects premiums from direct contributors and subsidies from sin tax for indirect contributors.

    • Other sources include national government shares from gaming and charity funds.

  2. Pooling of Funds

    • Pooled financial resources provide broad population coverage.

    • Individual-based services sourced from PhilHealth; population-based primarily from DOH and LGU budget appropriations.

  3. Purchasing of Services

    • PhilHealth aims for efficient allocation and provider payment mechanisms to ensure effective resource utilization.

Page 4: Special Health Fund Management

Integration of Local Health Financing

  • The SHF integrates local health financing systems, requires commitment from LGUs to manage funds effectively.

  • Joint guidelines issued by relevant agencies ensure strategic allocation and accountability.

Types of LGU Funds

  • General Fund: Covers unspecified expenses and obligations.

  • Special Fund: Used for specific purposes (trust fund and Special Education Fund).

  • SHF is a new fund only for provinces and highly urbanized cities.

Page 5: Sources and Uses of the Special Health Fund

Sources of the SHF

  • Comprised of:

    • National government agency grants (DOH).

    • Premium payments from PhilHealth members.

    • Donations and grants from NGOs and international partners.

Uses of the SHF

  • Funded activities include population-based and individual-based services, health system costs, and worker remuneration.

Page 6: Specific Allowable Uses of the SHF

Allowable Expenditures

  • Population-based services include:

    • Environmental health services, health promotion, epidemiological activities, and public health emergency responses.

  • Individual-based services consist of:

    • Inpatient and outpatient care, medication, and laboratory procedures.

  • Operational costs cover management, training, and transport costs.

Page 7: Remuneration and Health Worker Incentives

Health Worker Funding

  • SHF can be used for incentivizing health workers until LGUs create and fill plantilla positions.

  • Additional remuneration based on government salary standards.

Page 8: Management Responsibilities

P/CHB Management

  • Provincial or City Health Boards (P/CHB) manage the SHF, ensuring optimal resource use.

  • Coordination with budget and financial officers is essential for effective fund management.

Page 9: Fund Management Process

Management Steps

  1. Planning and Budgeting

    • Formulate local investment plans based on health needs.

  2. Disbursement and Utilization

    • Fund usage must comply with legal requirements and authorized expenses.

  3. Monitoring and Accountability

    • Ongoing tracking of fund usage with penalties for mismanagement.

Page 10: Transition to Global Budget Mechanisms

Global Budget as Payment Method

  • Prospective provider payments are based on total projected cost over a given period.

  • Single payments will cover all services rather than itemized billing.

Page 11: Diagnosis-Related Groups (DRGs)

DRG Payment Mechanism

  • Classifies cases for standard payment based on shared characteristics like procedures and expected resources used.

Page 12: Capitation as a Payment Mechanism

Capitation Overview

  • Fixed rate paid to facilities for a range of services for a specified period.

  • Intended for primary care service models.

Page 13: Workflow of Disease-Based Payment

Steps in the Payment Process

  1. Patients receive care in accredited facilities.

  2. Clinical histories are recorded and claims are submitted.

  3. Claims processed by DRG groupers for payments based on diagnoses.

Page 14: Cost-sharing Mechanisms

Definitions and Policies

  • Cost-sharing includes co-payments and co-insurance; PhilHealth introduces no co-payment options under UHC Act.

Page 15: Comparison of Policies

No Balance Billing vs. No Co-Payment

  • No Balance Billing is specific to certain membership categories, while No Co-payment applies universally under specific conditions.

Page 16: Bed Allocation Policies

Regulatory Requirements

  • Hospitals must maintain a percentage of beds for basic or ward accommodation, with specified limits for government and private facilities.