Updates on the 23 Case Rates and the

All Case Rates Initiatives

Utilization Review of Case Rates

Sept 2011 to May 2012

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

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Overall Utilization of Medical Case Ratesby Membership Type, Sept 2011 to May 2012

OWP

Lifetime

IPP

Employed

Sponsored0

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Overall Utilization of Surgical Case Ratesby Membership Type, Sept 2011 to May 2012

OWP

Lifetime

IPP

Employed

Sponsored

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

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140,000

Sep Oct Nov Dec Jan Feb Mar Apr May

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Utilization of Medical Case RatesSept 2011 to May 2012

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2011 2012

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Utilization of Surgical Case RatesSept 2011 to May 2012

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%)

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Comparison of Volume of Claims for Medical Conditions, FFS vs.Case Rates

FFSSept 09toMay 10

CRSept 11toMay 12

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Comparison of Volume of Claims for Surgical Conditions, FFS vs.Case Rates

FFSSept 09toMay 10

CRSept 11toMay 12

Review of Case Rates

• Improved turn-around time from >70 days to 45-50 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.

FFS Partial Case Rates

All Case Rates

Advantageous to PhilHealthContain the excesses of HCPs without sacrificing support to membersImprove turn-around-timeMake the benefits easier to communicateAllow PhilHealth to introduce incentives and NBBImprove transparency and predictability i.e. members know their benefitsPush health care providers toward better efficiency

All Case Rates Policy

Conceptual Framework

Fee for Service Case Rates

Incentive for efficiency Incentive for quality

Equitable distribution of reimbursement and

better resource management

Critical Step in the Creation and

development of a policy and regulatory

environment for Financial Risk Protection

Co-pay policies and No Balance billing

Outcomes-basedFacilities enhancements

2010 Premium Payment 29.087 Billion

Benefit payment 30.513 Billion

No of claims 3,479,453 Total benefit payment(in million pesos)

30,513.1

Total benefit payments for drugs and medicines

29%(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.

Benefit Payment 2010

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

• 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”.

Message to Providers

• stable claims• no fraud/up casing

PROCESS:

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

Method

AVPC of all ICD 10 codes + 20% of the AVPC

Comparison with existing case rates,

PF study, actual rates in database

Medical Case Rates

• Why AVPC?• Source of available data is PHIC dbase• No fair costing studies on PF and hospital charges

Surgical Case Rates

Method

RVU Computation ProfessionalFee Facility Fee

RVU < 200 A (RVU x 56 x 1.5)/0.4

40% of A 60% of A

RVU 200 –300

0.8 x A = B (RVU x 56 x 1.5)/0.5

50% of B 50% of B

RVU > 300 0.67 x A = C (RVU x 56 x 1.5)/0.6

60% of C 40% of C

RVU-based rates (A)= (RVU x 56 x1.5) /0.4

• Why RVU?• To make PF rate Commensurate to the level expertise of doctors and receive

what they used to get from PHIC

Method1. Conditions and procedures of similar nature and management were

grouped together2. 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 claimsc. 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 societies5. Consultation with societies to verify/validate groups and identify

admissions criteria6. Adjust groups and rates based on consultation7. Actuarial evaluation and projection on proposed case rates

• 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

Case Rate Averages and Messages

• 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”.

Message to Providers

COMBINATION OF RATES

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

100% Primary Case

Rate

% for the other surgical

case rates

Procedures done in one

operative session. One

incision

100% Primary Case

Rate

%Secondary Case Rate

One operative session, multiple incisions

100% Primary Case

Rate

%Secondary Case Rate

Different operative

sessions, one confinement

Thank You