Updates on the 23 Case Rates and the All Case Rates Initiatives

Transcription

1 Updates on the 23 Case Rates and the All Case Rates Initiatives

2 Utilization Review of Case Rates Sept 2011 to May 2012

3 Utilization Review of Case Rates The total volume of claims based on date of admission for all the case rate conditions covering all membership types is 2,150,857 Of the total claims filed (including FFS), 46% are under case rate Of the total case rate claims, 43% are under medical conditions and the highest number of claims are Pneumonia cases 57% came from surgical conditions and the highest number of claims are Hemodialysis cases Most case rate claims were availed by members from the employed sector Overall Utilization of Medical Case Rates by Membership Type, Sept 2011 to May Overall Utilization of Surgical Case Rates by Membership Type, Sept 2011 to May 2012 number of claims OWP Lifetime IPP Employed Sponsored number of claims OWP Lifetime IPP Employed Sponsored

4 Utilization Review of Case Rates There is an average 3% decrease in the availment of Medical Case Rates from Sept 2011 to May 2012 However, in the same period, there is an average 5% increase in the availment of Surgical Case Rate conditions 140,000 Utilization of Medical Case Rates Sept 2011 to May ,000 Utilization of Surgical Case Rates Sept 2011 to May 2012 number of claims 120, ,000 80,000 60,000 40,000 20,000 number of claims 160, , , ,000 80,000 60,000 40,000 20,000 - Sep Oct Nov Dec Jan Feb Mar Apr May - Sep Oct Nov Dec Jan Feb Mar Apr May

5 Comparative Review of Case Rate Conditions Comparing utilization of similar condition with the Sept 09 to May 10 under FFS, Pneumonia and Hemodialysis topped the cause of admission for medical and surgical, respectively A significant increase in the volume of claims for Hemodialysis was noted (150%) Comparison of Volume of Claims for Medical Conditions, FFS vs.case Rates Comparison of Volume of Claims for Surgical Conditions, FFS vs.case Rates number of claims FFS Sept 09 to May 10 CR Sept 11 to May 12 number of claims FFS Sept 09 to May 10 CR Sept 11 to May

6 Review of Case Rates Improved turn-around time from >70 days to days for Case Rate claims Introduced the No Balance Billing Policy for Sponsored Program members However only 15% surveyed are true NBB. World Bank s study on Costing local government hospitals gained. DOH hospitals either are break even or lost.

7 FFS Partial Case Rates All Case Rates Advantageous to PhilHealth Contain the excesses of HCPs without sacrificing support to members Improve turn-around-time Make the benefits easier to communicate Allow PhilHealth to introduce incentives and NBB Improve transparency and predictability i.e. members know their benefits Push health care providers toward better efficiency All Case Rates Policy

8 Conceptual Framework Fee for Service Case Rates Incentive for efficiency Incentive for quality Critical Step in the Creation and development of a policy and regulatory environment for Financial Risk Protection Equitable distribution of reimbursement and better resource management Outcomes-based Facilities enhancements Co-pay policies and No Balance billing

9 2010 Premium Payment Billion Benefit payment Billion No of claims 3,479,453 Total benefit payment (in million pesos) Total benefit payments for drugs and medicines 30, % (PHP 8,848,794,079) For the first time in the history of the NHIP, PhilHealth paid more in benefits than it collected in premium contributions: a difference of 1.5 billion pesos.

10 Benefit Payment 2010 Medicines comprise about 29% of the total amount paid by PhilHealth amounting to PHP 9B

11 Message to Providers Messages Case Rates and NBB are related but are different concepts. Case rates apply to all. NBB only for the sponsored in government wards. NBB patients are those that used to not afford to pay but now will be able to through PhilHealth. (new markets) Currently, for non-sponsored member types, there is co-pay. But co-pay is not fixed to the detriment of the next poor.

12 PROCESS: stable claims no fraud/up casing

13 Methodology COSTING Using 2 sets of codes: ICD 10 for medical conditions RVS for procedures ISSUES GROUPING Conditions and procedures of similar nature and management were grouped together

14 Method Medical Case Rates AVPC of all ICD 10 codes + 20% of the AVPC Comparison with existing case rates, PF study, actual rates in database Why AVPC? Source of available data is PHIC dbase No fair costing studies on PF and hospital charges

15 Surgical Case Rates Method RVU-based rates (A) = (RVU x 56 x1.5) /0.4 RVU Computation RVU < 200 A (RVU x 56 x 1.5)/0.4 RVU x A = B (RVU x 56 x 1.5)/0.5 RVU > x A = C (RVU x 56 x 1.5)/0.6 Professional Fee Facility Fee 40% of A 60% of A 50% of B 50% of B 60% of C 40% of C Why RVU? To make PF rate Commensurate to the level expertise of doctors and receive what they used to get from PHIC

16 Method 1. Conditions and procedures of similar nature and management were grouped together 2. Review of grouping a. Objective: to validate the ICD codes within the group and rates of the group; to determine if effect of proposed policies to the grouping and vice versa; b. Initial review: 65 groups make up 85% of conditions claims c. Still for review: 110 procedures comprise 90% of all procedure claims 3. Specialty societies were asked to submit a list of their most commonly claimed conditions and procedures (7 societies out of 22 replied so far) 4. Comparison of IPT proposed rates with rates from specialty societies 5. Consultation with societies to verify/validate groups and identify admissions criteria 6. Adjust groups and rates based on consultation 7. Actuarial evaluation and projection on proposed case rates

17 Case Rate Averages and Messages Why these methodologies? We need extensive researches such as a transparent Professional Fee Study and accurate government costing for basic quality services for the poor but we cannot do this immediately. But we need to go all case rates in order to sustain the gains, improve financial protection through equitable payments, and improve the understanding of our members on their benefits

18 Message to Providers Messages Case Rates and NBB are related but are different concepts. Case rates apply to all. NBB only for the sponsored in government wards. NBB patients are those that used to not afford to pay but now will be able to through PhilHealth. (new markets) Currently, for non-sponsored member types, there is co-pay. But co-pay is not fixed to the detriment of the next poor.

19 COMBINATION OF RATES

20 100% Main Condition % for the other conditions Combination of Medical Case Rates 100% Main Condition/ Primary case rate % of Secondary Case Rate Combination of Medical & Surgical Case Rates

21 100% Primary Case Rate 100% Primary Case Rate % for the other surgical case rates % Secondary Case Rate Procedures done in one operative session. One incision One operative session, multiple incisions 100% Primary Case Rate % Secondary Case Rate Different operative sessions, one confinement

22 Thank You