PhilHealth expands outpatient benefits for sponsored members

Friday 15th of June 2012

CEBU CITY, June 15 (PIA) -- PhilHealth now expands its Outpatient Benefit (OPB) package for sponsored members to promote healthy behavior and ensure utilization of services paid for under the package and provide incentives to providers who perform better.

Now, the Primary Care Benefit 1 (PCB1) package for sponsored members is consistent with the health care reform objectives of Universal Health Care. It is also designed to help achieve the health-related Millennium Development Goals (MDG) of the country.

The old OPB package covers specific primary preventive care and diagnostic services in rural health units (RHU) or health centers (HC) for a particular period that PhilHealth pays through a per capita payment scheme.

The amount of coverage per capita is P300 and the basis for payment depends on the number of sponsored members in a local government unit (LGU).

Under PhilHealth Circular 10-2012, the PCB1 package covers primary preventive care and diagnostic services that now include tests for lipid profile and fasting blood sugar, and drugs and medicines for outpatient treatment of asthma, upper respiratory tract infection or low risk pneumonia, acute gastroenteritis with no or mild dehydration and urinary tract infection.

Three primary preventive care services are now considered obligated under the package: clinical breast exam, visual inspection with acetic acid and blood pressure measurement, the PHIC said.

PCB1 still covers sponsored members under the National Household Targeting System for Poverty Reduction (NHTS-PR) and sponsored members subsidized by legislative, local government and private sponsors.

But this time, coverage now extends to PhilHealth members under the Overseas Workers Program (OWP) and organized group (OG) members. OWP members are land-based overseas Filipino workers (OFW) who pay an annual premium of P2,400, while OG members are individuals enrolled as a group under PhilHealth's Individually Paying Program (IPP).

Previously, only RHUs or HCs are considered providers of the OPB package, except in cases where an LGU's RHU is not PhilHealth accredited, in which case, the outpatient department of an accredited government hospital in that city or municipality may apply as provider.

With the PCB1, however, any qualified and capable government facility (hospital or non-hospital) can apply as provider.

Further, capitation payment under the PCB1 is now a per family payment rate (PFPR) so that the amount of payment now depends on the number of members and qualified dependents served.

Provider performance is also now significantly linked to capitation payment. PhilHealth pays the PCB1 provider based, not just on the number of sponsored members assigned to a provider, but on the number of members they are able to enlist and profile (initial and updated health profile), and the number of members actually provided with the obligated services.

PhilHealth urges local chief executives to encourage better performance through the proper disposition and allocation of 20 percent of the capitation payment as honoraria of the health and non-health personnel involved in the delivery of PCB1 services.

The remaining 80 percent of capitation payment is allocated for drugs and medicines, which should be no less than half of that percentage; and the other half for reagents, medical supplies, equipment, IT, capacity building for staff, infrastructure, or any other use related and/or necessary for the delivery of the required services, including referral fees for diagnostic services if not available in the facility.

PhilHealth encourages all sponsored, OFW and OG members and qualified dependents to approach the RHU or HC nearest them and enlist on or before June 30 so they can be profiled and apprised of their entitlements under the package. (PhilHealth/MBCN/HFG-PIA7)