Experiences with Insurance Coverage of Medicines in the Philippines

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Experiences with Insurance Coverage of Medicines
in the Philippines Dr. Madeleine R. Valera
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The Vision for our Future
A premiere government corporation that ensures
sustainable, affordable, and progressive social
health insurance which endeavors the delivery of
accessible quality health care for all
Filipinos.
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Our Mission
As a financial intermediary, PhilHealth shall
continuously evolve a sustainable NHIP that
shall

• Lead towards universal coverage

• Ensure better benefits for its members at
  affordable premiums

• Establish close coordination with its clients
  through a strong partnership with all
  stakeholders and,

• Provide effective internal information and
  management systems to influence the delivery of
  quality health care services

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Republic Act 7875 of 1995
Universality
Social Solidarity
Care for the Indigent
Quality Assurance
LGU Participation
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PhilHealth Membership Base
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Accreditation of Service Providers
1,534 Health Facilities
20,259 Professionals
573 RHUs
8 Anti-TB/DOTS Centers
12 Free-standing Dialysis Clinics
34 Maternity Care Clinics
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Benefit Package
Room Board Drugs and Medicines X-ray,
Laboratory, etc. Professional Fees Operating
Room Surgeon Anesthesiologist
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TO IMPROVE HEALTH

• positive drug list
• benefit packages
• TB DOTs Package
• Maternity Care Package
• improve access to affordable quality drugs
• - promotion of good manufacturing practice
• - Drug Price Reference Index (DPRI)

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LEVERAGING INDUSTRY
PHIC as one of the largest third party purchasers
of health care with both power and mandate to
push for low cost quality drug

• Drug Price Reference Index (DPRI) to address
• Irrational drug pricing
• Price transparency

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INFLUENCE PROVIDER PRACTICE

• Health Technology Assessment (HTA)
• Accreditation of Providers
• Researches
• - Internal Peer Review, Hospital Outliers,
  Drug Utilization Review of Antibiotics, Positive
  List Study, Social Marketing Study, DPRI
  Longitudinal Study
• Utilization Review and Peer Review
• Support to the Generic Law
• Medical Informatics (Database of illness)
• - ICD-10 to standardize diagnosis and
  treatment

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CHALLENGES

• Laissez-faire attitude of doctors
• Breaking the bank
• Membership sustainability
• Partnership with consumer groups
• Political patronage
• Weak government regulatory function
• Influence of drug manufacturers on doctors
• No regulatory powers to control prices
• Drug Price Reference Index Implementation

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OPPORTUNITIES

• Strategic role of PhilHealth
• Government Health Sector Reform
• Practical demographics
• International advocacy and support
• Low membership easier to negotiate with
  providers
• Coverage of outpatient drugs

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FUTURE GLOBAL AGENDA
1. Cost containment with access to quality drugs

2. Concerted effort with the private sector and
academe
3. Co-financing drugs and medicine
4. Continuous commitment to rational drug use
5. Enhanced collaboration towards participatory
evidence-based medicine including
consumers/clients
6. Effective communication thru social marketing
7. Capacity building
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No profession brings perfection No program
accomplishes fully the vision and mission of
development No set of goals include everything We
simply plant seeds today that one day will
grow We water seeds already planted, knowing that
they hold the future promise We lay foundations
that will need further development We provide the
yeast that produces effect far beyond our
capability We cannot do everything This enables
us to do something and do it very well It may be
incomplete, but is the beginning a step along the
way
- Archbishop Romero