Module 2: Universal Health Care
DOH; Philhealth
That the _____________, in coordination with ______________, shall promulgate the guidelines on the registration of every Filipino to a primary care provider that stipulate the standard processes, procedures, guidelines, form, and data management, among others.
Expansion of Scholarships for Health
The DOH and CHED shall increase production of identified cadre of health professionals and health managers as determined by the National Health Human Resource Master Plan through the expansion and redirection of government-funded scholarship programs that would support the production of needed cadre of health care professionals, health care workers, and health managers and improve local retention. That bona fide residents of underserved and unserved areas or members of indigenous peoples shall be prioritized for scholarship grants from the national government, LGUs, NGOs or private entities, and international bodies.
Government funded scholarship programs
The DOH and CHED shall source funds for scholarship grants; refer to a modality of financial assistance that they provide to eligible individuals through ________________.
Return Service Agreement
The DOH and CHED, in consultation with SUCs, Local Universities and Colleges, and private academic and training institutions with health professional education programs shall institutionalize mechanisms to encourage their graduates to serve in priority areas and field of practice in the public sector.
Primary Care Provider (PCP) (RA 11223 Sec 6)
The DOH and LGUs shall endeavor to provide a health care delivery system that shall afford every Filipino a _________________.
1. Monitor the prices of health services, which include among others, laboratory fees, cost of procedures, cost of amenities, professional fees, and other health services provided by hospitals and other health care providers; Provided, That the collection, submission, and publication of price data as required by law shall form part of data submission to PhilHealth; and, 2. Monitor the prices of all health goods such as drugs and medicines, health and medical devices, and laboratory and medical supplies.
The DOH and PhilHealth shall issue policies and procedures, as well as establish systems to undertake the following functions:
Monitoring System
The DOH and academic or training institutions, whether public or private, with government-funded scholarship programs shall set up a _______________.
1. eligibility requirements 2. standard competencies 3. training mechanisms, and 4. post-graduate certification process
The DOH and the PRC shall issue the following guidelines for primary care workers:
DOH; PhiliHealth
The ___________ and ___________ shall issue the guidelines on submission of information and public access to said information regarding the prices and charges for all goods and services, including professional fees being offered by health care providers and health care provider networks.
DOH
The ____________ shall issue guidelines that specify conditions for admission of scholarship recipients into post-graduate degree programs or specialty training courses under the RSA.
PRC; doh
The _____________, together with their accredited medical and allied health professional organizations (APO) and other national and local bodies, within their mandates, shall provide the DOH with relevant health care professional and health care worker data. ____________ is authorized to collect data and information for the national health workforce registry from relevant agencies, including NGOs, private organizations and facilities
DOH
The _______________ shall establish a mechanism for the development, adoption and dissemination of Consumer packaged goods (CPGs); Provided, That DOH and PhilHealth shall monitor compliance to such CPGs.
Universal Healthcare (UHC)
The belief that all citizens should have access to affordable high-quality medical and healthcare services
Prepayment
Refers to an approach in the purchase of health services by which health care providers are paid in advance for the cost of goods and services for a specific package of health benefits based solely on a pre-determined and fixed budget.
Health Maintenance Organization (HMO)
Refers to an entity that provides, offers, or covers designated health services for its plan holders or members for a fixed prepaid premium.
Public Health Emergency
Refers to an occurrence or imminent threat of an illness or health condition.
Primary care practice
Refers to the exercise of duties and responsibilities of multidisciplinary team of health workers which shall be eligible to be assigned to a catchment area/population in a primary care facility.
Primary care facility
Refers to the institution that primarily delivers primary care services which shall be licensed or registered by the DOH.
Health Technology Assessment (HTA)
Refers to the systematic evaluation of properties, effects, or impact of health-related technologies, devices, medicines, vaccines, procedures and all other health-related systems developed to solve a health problem and improve quality of lives and health outcomes, utilizing a multidisciplinary process to evaluate the social, economic, organizational, and ethical issues of a health intervention or health technology.
Government general hospitals
Regardless of size and level, are required to operate not less than ninety percent (90%) of their authorized bed capacity as basic or ward accommodation.
Number of practitioners; location of practice
Registry of health professionals workers states that the PRC and the DOH in coordination with duly registered medical and allied health professional societies or the Accredited Professional Organization (APO) shall set up a registry of medical and allied health professionals indicating among others their current ___________ and ____________.
National Health Human Resource Master Plan
Relevant national government agencies, LGUs, and the private sector, shall ensure the availability of sufficient resources to implement the National Health Human Resource Master Plan; Provided, That the province-wide and city-wide health systems shall align their investment needs with the Plan.
Private hospitals
Required to operate not less than ten percent (10%) of their authorized bed capacity as basic or ward accommodation.
1. To negotiate prices guided by certain parameters including new health technology, innovator drugs, and sourced from a single supplier
Responsibilities of Central Price Negotiation Board for Health Technologies
Responsibilities of CHED and TESDA on the Training Programs
Review and update, as necessary, all recognition or accreditation policies and guidelines for health education programs, prioritizing the expansion of undersubscribed courses Develop support programs to assist graduates acquire necessary and relevant qualifications, such as professional licenses for practice or civil service eligibility for those who wish to be employed in government Develop new programs in coordination with the DOH to supply the health care provider networks with practice-ready health and allied health care professional and health care workers to meet health workforce requirements Regulate the number of enrollees per program in favor of producing sufficient allied and health-related degree graduates based on the health needs of the population, especially those in the underserved and unserved areas, and enforce stricter admission policies and guidelines to reduce student and trainee attrition rates Promote and support the establishment of medical and health science schools and technology vocational training providers in regions where health care professionals and health care workers are inadequate and production capacity is limited by the lack of accessible training facilities or health professional education programs Regulate the quality of education of medical and allied health schools and technical-vocational education and training providers and take necessary actions to enforce quality standards.
Responsibilities of PRC on the Training Programs
Review and update, if necessary, the accreditation standards and admission policies or requirements for medical residency and sub-specialty training and specialization tracks for allied health professions to support reducing trainee attrition rates Regulate the number of trainees per program in favor of producing enough medical and allied health professionals with appropriate competencies for primary and specialty practice, based on the health needs of the population and priorities identified by the DOH, especially those in GIDAs Assist national government agencies, LGUs, and the private sector in the establishment of accredited programs for medical residency and sub-specialty training, and specialization tracks for allied health professions, where feasible, in provinces where specialists or sub- specialists and allied health professionals are in shortage.
Population-based and individual-based
Services that meet both ______________ and ____________ health services criteria, or neither of the criteria, shall retain its current financing mechanism DOH and PhilHealth shall issue the guidelines for implementing this provision.
Primary Care Provider (PCP)
Shall act as the navigator, initial and continuing point of contact in health care delivery system; Provided, That except in emergency or serious cases and when proximity is a concern, access to higher levels of care shall be coordinated by the primary care provider.
DOH, CHED, and PRC
Shall develop guidelines for noncompliance and mechanisms to define obligations for recipients of scholarship grants who fail to render return service.
National government
Shall support LGUs in the financing of capital investments and provision of population-based health services.
1. Health Financing 2. Service Delivery 3. Policy, Standards, and Regulation 4. Governance for Health 5. Human Resources for Health 6. Health Information
Six (6) Building Blocks of Universal Health Care (UHC)
Socio-economic factors
Social, cultural, and economic characteristics of the community that limit access to and utilization of health services.
1. Raise enough revenues 2. Manage revenues to pool health risk equitable and efficient 3. Ensure that the payment for our purchase of health services is carried out in ways that are allocatively and technically efficient.
Three (3) Basic Principles of Public Financing for Health
1. Full or supplementary payment for subsidies to complete tuition fees. 2. Living allowances 3. Free books and uniform
Three (3) Government funded scholarship programs
1. Financial risk protection 2. Access to quality health facilities and services 3. Attainment of Millennium Development Goals (MDG) max
Three (3) Strategic Thrusts defined by DOH to achieve UHC
1. Hospitals use a large percentage of total health expenditure 2. High-cost health technologies are concentrated in hospitals 3. The way we pay hospitals significantly influence certain performance measures of the health sector
Three (3) importance of hospital service cost in financing
Policy, Standards, and Regulation
To ensure equitable access to health services, essential medicines and technologies of assured quality, availability and safety.
Human Resources for Health
To ensure that all Filipinos have access to professional health-care providers, capable of meeting their health needs at the appropriate level of care.
Health Information
To establish a modern information system that will provide evidence for policy and program development, and support for immediate and efficient provision of health care and management of province-wide health systems.
Governance for Health
To establish the mechanisms for efficiency, transparency and accountability and prevent opportunities for fraud.
Public health unit
To facilitate the provision of population-based health services, a ________________ shall be established in all hospitals to support the implementation of national public health programs; institutionalize a coordination mechanism with primary care provider networks; and provide a one-stop shop patient navigation support mechanism within the hospital.
Health Financing
To increase resources for health that will be effectively allocated and utilized to improve the financial protection of the poor and vulnerable sectors.
Service Delivery
To transform the health service delivery structure to address variations in health service utilization and health outcomes across socioeconomic variables.
1. Progressively realize universal health care in the country through a systematic approach and clear delineation of roles of key agencies and stakeholders towards better performances in the health system. 2. Ensure that all Filipinos are guaranteed equitable access to quality and affordable health care goods and services, and protected against financial risk.
Two (2) objectives of Universal Health Care Act (RA 11223)
Population-based Health Services
Under health service packages/delivery (RA 11223 Sec 17) Intended to be received by populations or identified groups of people, of which outcomes contribute to the general public health, safety and protection. Rendered in response to a public health emergency or disaster or any circumstance of equal magnitude, such as diseases for elimination, that has affected, or can potentially affect, a population.
Individual-Based Health Services
Under health service packages/delivery (RA 11223 Sec 17) One (1) recipient has limited effect at a population level, and does not alter the underlying cause of illness.
Province-wide and city-wide health systems
____________ and ____________ shall ensure funding for effective health operations and conduct of activities such as but not limited to capacity building, research, and health promotion consistent with national guidelines and with support from the DOH.
Drug Price Reference Index (DPRI)
_______________ lists the mandated ceiling prices for the public sourcing of essential medicines by government hospitals and Regional Health Offices (RHOs) under the jurisdiction of the DOH. It should also serve as a guide to all government entities to rationalize the procurement prices of medicines in the public sector.
Drug outlets
_______________ shall be required at all times to make available and offer fairly priced generic equivalent of all drugs in the DOH Primary Care Formulary (PCF) based on the local needs and prevailing disease patterns in the community.
Financing of Health Services (RA 11223 Sec 7, Sec 17 and Sec 18)
Population-based health services shall be financed by the national government through the DOH and provided free of charge at point of service for all Filipinos.
DOH-owned; price structure
Prescribed Mark-ups for Drugs, Medical Devices and Supplies states that all ____________ health care facilities shall submit to the DOH all relevant costs and information necessary for the creation of a mark-up structure for drugs, medical devices and supplies. All DOH-owned health care facilities shall adhere to the ______________ and SHALL NOT go beyond the prescribed mark-ups for drugs, medical devices and supplies.
Rules and structures
Prescribed Mark-ups for Drugs, Medical Devices and Supplies states that the DOH shall prescribe uniform ___________ and ___________ in setting mark-ups for drugs, medical devices and supplies that shall be applied by DOH-owned health facilities on top of the price reference indices to protect patients from excessive and unnecessary charges.
Prospective payment
Refers to a method of reimbursement in which payment is based on a predetermined, fixed amount. The payment amount for a particular service is based on disease or diagnosis-related groupings and validated costing methodologies.
DOH
The _________ shall issue guidelines for the licensing of primary care providers.
LGU; DOH; PhilHealth
The __________, with the assistance from ___________ and __________, shall register their respective constituents to a primary care provider within their territorial jurisdiction.
1. DOH shall issue guidelines as to the structure and constitution of such board 2. The negotiated price in the framework contract shall be applicable for all healthcare providers under DOH 3. The board shall adhere to the guidelines issued by the GPPB.
Provisions of Central Price Negotiation Board for Health Technologies
Multi-year
A ______________ framework contracts may be implemented by the DOH in accordance with RA 9184 (Government Procurement Reform Act) and other GPPB issuances to ensure the continuous availability of drugs, medical devices and supplies centrally negotiated by the price negotiation board at affordable prices, which shall be applicable throughout the term of the contracts.
Health Technology Assessment (HTA)
A fair and transparent _________ process, shall govern the inclusion of health goods and services to which every Filipino is eligible to access through PhilHealth and DOH.
National Health Workforce Support System (RA 11223 Sec 24)
Refers to a mechanism that will support equity in local public health systems of deployed health care professionals or health care workers.
Equity
(RA 11223 Sec 29)
Service Coverage (RA 11223 Sec 6)
Every Filipino shall be granted immediate eligibility and access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental and emergency health services, delivered as population-based or individual based health services.
Registration of Filipinos to Primary Care Provider Networks (RA 11223 Sec 6)
Every Filipino shall register with a public or private primary care provider of choice with due consideration to proximity and ease of travel of those seeking care, absorptive capacity of the provider for quality care, and provider capability to deliver the required services, among others.
Return Service Agreement (RSA)
All graduates of allied and health-related courses who are recipients of government funded scholarship programs must enter into a __________________ with both the academic or training institution or training facility and the DOH.
Universal Health Care (UHC)
Also known as Kalusugan Pangkalahatan (KP) A health reformed initiated in 2010 through the issuance of Administrative No. 2010-0036.
Universal Health Care Act: A new dawn for healthcare
Also known as RA 11223 Automatically enrolls all Filipino citizens in the National Health Insurance Program and prescribes complementary reforms in the health systems.
Service Delivery Networks (SDNs)
An ____________ refers to the network of public and private health providers within local health systems offering a core package of health services in an integrated and coordinated manner as a form of health referral within and outside the DOH, including with LGUs, development partners and civil society groups.
Universal Health Care Act (RA 11223)
An act instituting Universal Health Care for all Filipinos, prescribing reform in the health care systems, and appropriating funds.
Responsibilities of DOH on the Training Programs
Assist national government agencies, LGUs, and the private sector in the establishment of accredited programs for medical residency and subspecialty training, and specialization tracks for allied health professions to produce specialists and sub-specialists in underserved and unserved areas Regularly provide updates to the PRC, CHED, and TESDA of the number and distribution of the health workforce to support the coordinated and balanced production of health professionals and health workers, as well as the health service needs of underserved and unserved areas and populations.
Expansion of Degree and Non-Degree Training Programs
CHED, TESDA, PRC and DOH shall develop and plan the expansion of existing and new allied and health-related degree and training programs based on the health needs of the population especially those in GIDAs. It shall be incorporated into the National Health Human Resource Master Plan which becomes the basis of the number including categories, where applicable, of health care professionals and health care workers needed to meet the health needs of the population, especially those in underserved and unserved areas.
Physical factors
Characteristics that limit the delivery of and/or access to basic health services to communities that are difficult to reach due to distance, weather conditions, and transportation difficulties.
1. Comprehensive health labor market study adopting a whole of society approach 2. Standards for human resources for health (HRH), in both public and private sector, on staffing requirements, appropriate generation, recruitment, retraining, regulation, retention, productivity mechanisms, and reassessment of the health workforce that would be updated to accommodate changing population health needs 3. Outcomes pertaining to sustainable production, appropriate skill mix retention in the health sector, equitable distribution and practice-ready training and education for HRH.
Components of National Health Human Resource Master Plan
1. DOH Representative 2. PhilHealth Representative 3. Department of Trade and Industry (DTI) representative
Composition of the board of Central Price Negotiation Board for Health Technologies
1. Services of health care professionals; 2. Diagnostic, laboratory, dental and other medical services; 3. Personal preventive services; 4. Prescription drugs and biologicals, subject to the limitations of the Act 4. Other services deemed appropriate.
Comprehensive outpatient benefits (RA 1123 Sec 6) shall include, but are not limited to:
Individual-based health services
DOH and PhilHealth, in consultation with the Insurance Commission, private health insurance and HMOs, shall issue guidelines and monitoring schemes in order to rationalize financing schemes and to ensure that there is complementation in the financing coverage of _________________.
National Health Workforce Support System
DOH shall secure positions to hire health professionals and health workers for deployment under the _______________. This is to augment health workforce needs of local public health systems.
Geographically Isolated and Disadvantaged (GIDA)
Deployment of health professionals and health workers shall prioritize _____________. Graduates of medical and allied health professions who are recipients of government-funded scholarship programs shall be prioritized in the recruitment and selection to the allocated positions.
Safety and Effectiveness
Each intervention, especially drugs and medicines, shall undergo Phase IV clinical trial, and systematic review and meta-analysis must be readily available, as deemed necessary. For long term safety data, other sources of clinical evidence may be used in the HTA process, such as reports of adverse drugs events to the FDA, case reports, case series and real-world data.
Specialty hospitals
Either single-specialty or multi-specialty government hospitals as designated by the DOH, are required to operate not less than seventy percent (70%) of their authorized bed capacity as basic or ward accommodation.
Employment-based private insurance
Employers usually pay all or part of the premium that purchases health insurance for their employees.
Okun 1975
Equal treatment for equal need. ("economic inequalities that stem from inequality of opportunity are more Intolerable than those that emerge when opportunities are equal")
Bed Capacity of Hospitals
Equity (RA 11223 Sec 29) Currently licensed hospitals shall fully comply with the required allocation of beds for basic or ward accommodation subject to the guidelines that will be issued by the DOH; Provided, That the required allocation of beds for basic or ward accommodation shall be immediately applicable to new hospitals applying for License to Operate. All government general hospitals, specialty hospitals, and private hospitals are required to annually submit a report, through a DOH online reporting system, on the allotment and actual utilization of the authorized beds for basic or ward accommodation, in compliance to licensing requirements.
Population Coverage (RA 11223 Sec 5)
Every Filipino citizen shall be automatically included into the National Health Insurance Program (NHIP). The database of all the Filipino citizens shall be consolidated by the Philippine Health Insurance Corporation (PhilHealth) without prejudice to future laws or guidelines that may affect the identification or enumeration of Filipinos. PhilHealth shall coordinate with other national government agencies (NGAs) such as but not limited to the:
1. Responsiveness to Magnitude, Severity, and Equity 2. Safety and Effectiveness 3. Household Financial Impact 4. Cost-effectiveness 5. Affordability and Viability
Five (5) Criteria in the Conduct of HTA (RA11223 Sec 34)
1. provide primary care services 2. Serve as initial contact and navigator to guide patients' decision making for cost-efficient and appropriate levels of care, and coordinate patients to facilitate two-way referrals and remove barriers to health services 3. Enable patient records to be accessible throughout the health system 4. Implement public health services such as vector control and sanitation as may be determined by the DOH
Four (4) Functions of the Primary Care Provider Network (RA 11223 Sec 17)
3 full years; 1 year
Graduates entering into an RSA shall be required to serve in one of the DOH-specified priority health facilities or fields of practice, within the public sector in the Philippines, on a full-time basis for at least ______ full years, within ______ year upon graduation or upon acquiring the necessary license to practice; Provided, That those who will serve for additional two (2) years shall be provided with additional incentives as determined by the DOH.
Allied and health-related
Graduates of ______________ courses who are recipients of government-funded scholarship programs shall be prioritized for government employment and training opportunities, including permanent positions under province-wide or citywide health systems, positions for medical residency and sub-specialty training, and specialization tracks for allied health professions in government facilities, and shall receive standard compensation and benefits based on prevailing national rates for civil servants.
Culyer 1995
Health services are distributed NOT according to ability to pay, but according to medical need or capacity to benefit from a health service
PhilHealth; population-based services
In Financing of Health Services (RA 11223 Sec 7, Sec 17and Sec 18), all individual-based health services, including those transitioned from population-based health services, shall be covered by ________________. All current benefit packages of PhilHealth shall continue to be covered as individual-based services unless reclassified by the DOH as _______________.
Drug price reference index (DPRI)
In National Price Reference Indices for Drugs, Medical Devices and Supplies, The DOH shall expand the current ________________ implemented in DOH-owned health facilities and develop price reference indices before mark ups for drugs, medical devices and supplies. In establishing the price reference indices for drugs, medical devices and supplies, the DOH shall consider all factors relevant to their costs.
1. Reorient health care professional and health care worker curriculum towards primary health care, with emphasis on public health and primary care 2. Determine recommended areas of study in public health to be incorporated in the curriculum of all health sciences education 3. Incorporate educational outcomes focusing on primary care in the education programs; scope of licensure examinations, continuing professional development programs for health professionals; and, certification programs for health care workers.
In inclusion of Primary Care Competencies in Health Professional and Health Worker Curricula, CHED, PRC, and the DOH in coordination with duly registered medical and allied professional societies/APO, shall:
DOH; DOH
In national price reference indices for drugs, medical devices, and supplies, the _____________ shall update the price reference indices at least every year and make them public through various platforms, including web-based databases, price booklets, and publication in major newspapers. All ____________-owned health care facilities shall procure drugs, medical devices and supplies guided by the price reference indices in accordance with relevant laws, such as, RA 9184 (Government Procurement Reform Act) and RA 9502 (Cheaper Medicines Act of 2008).
Government-financed Insurance
In the late 1950s, less than 15% of the elderly had health insurance. In 1965, Medicare (for the elderly) and Medicare (for the poor) was enacted First-tax financed govt. insurance
Prepayment mechanisms
Individual-based health services shall be financed primarily through ________________ such as social health insurance, private health insurance, and HMO plans to ensure predictability of health expenditures.
Human Resources for Health (HRH) Network (RA 11223 Sec 23)
Institutionalized by DOH A multi-stakeholder composed of both public and private organizations and agencies
Individual private insurance
Involve an individual person paying a premium directly to a "health plan" or insurance company, which reimburses providers.
National Health Human Resource Master Plan
Long term strategic plan for the management and development of HRH; Provided, That the Plan shall be implemented at the national and local levels by both government and private sectors.
1. Fee for Service 2. Per Diem (per day) 3. Per Admission 4. Global Budget 5. Capitation (package per head/person) 6. Case Payment (based on diagnosis or diagnosis related groups
Methods of Healthcare Payment
New position
National Health Human Resource Master Plan states that the creation of _______________ as necessary to meet staffing standards to provide health services or implement health programs in priority areas of the government.
Permanent positions; competitive salaries
National Health Human Resource Master Plan states that the health professionals and health workers shall be hired in _______________ in province-wide and city-wide health systems. They should receive _______________ based on prevailing laws on salaries of civil servants.
Standard; competitive incentives; security of tenure
National Health Human Resource Master Plan states that there should be _______________ and _______________ for public health workers, barangay health workers and barangay nutrition scholars. To provide ______________ to those with eligibility.
Retailer; Drug outlet
No ____________ or ___________ shall withhold from sale or refuse to sell to consumers fairly priced generic equivalents of drugs in the PCF.
RA 9184; RA 9502; RA 7394
Noncompliance by the DOH-owned health facilities with the published price reference indices shall be subject to existing rules and administrative sanctions as stipulated in these Rules and other relevant laws such as _____________ (Government Procurement Reform Act), _____________ (Cheaper Medicines Act of 2008), and _____________ Consumer Act of the Philippines), among others.
RA 9711; RA 9502; RA 7394
Noncompliance to this specific provision shall be subject to administrative sanctions under these Rules and relevant laws such as the ____________ (Food and Drug Administration Act of 2009), _____________ (Cheaper Medicines Act of 2008), and _____________ (Consumer Act of the Philippines).
Human Resources for Health (HRH) Network (RA 11223 Sec 23)
OBJECTIVE: to formulate and oversee the sustainable implementation, monitoring, periodic evaluation, and reformulation of the National Health Human Resource Master Plan
1. Track scholarship recipients and graduates, 2. Monitor compliance to return service, and 3. Assess effectivity of the RSA
Objectives of Monitoring System
1. Measures on provision of complete and appropriate care, health outcomes, patient satisfaction, fund utilization and allocation of resources across health care providers and different levels of care 2. compliance to standards of clinical practice as approved by DOH 3. submission of price information of health goods and services 4. compliance to guidelines and standards as prescribed by DOH and PhilHealth and other applicable laws; and, 5. other measures or indicators as deemed necessary.
PhilHealth rating system shall include, but not limited to the following:
Payment mechanisms
PhilHealth shall adopt any or a combination of closed-end, prospective provider ______________, such as capitation, global budget, case-based payment, per diem or daily charges, and other appropriate mechanisms; Provided, That PhilHealth, in consultation with stakeholders shall issue guidelines for the implementation of provision.
Individual-based health services;
PhilHealth shall continue to finance _____________ utilizing current payment mechanisms such as capitation and case rate payments. For contracted networks and apex hospitals, it shall endeavor to shift to paying providers using performance driven, closed-end, prospective payments based on Diagnosis-Related Groupings (DRGs) and validated costing methodologies and without differentiating facility and professional fees.
Payment schemes
PhilHealth shall develop differential _______________ that give due consideration to service quality, efficiency, equity, and public health outcomes.
Service-level agreements
PhilHealth shall endeavor to contract public, private, or mixed health care provider networks through ________________ for the delivery of individual-based health services.
Incentive scheme
PhilHealth shall establish an _____________ in contracting DOH-licensed health facilities and services located in underserved and unserved areas that shall ensure sustainability of provision of safe and quality health services.
PhilHealth Rating System
PhilHealth shall establish an incentive scheme for health facilities to provide better service quality, efficiency, and equity based on a rating system.
Strong surveillance and audit mechanisms
PhilHealth shall institute ___________ and ____________ to ensure networks' compliance to contractual obligations.
1. Bioterrorism 2. Appearance of a novel or previously controlled or eradicated infectious agent or biological toxin 3. Natural disaster 4. Chemical attack or accidental release 5. Nuclear attack or accident 6. Attack or accidental release of radioactive materials
Public Health Emergency refers to an occurrence or imminent threat of an illness or health condition that is caused by any of the following:
Human Resources for Health
RA 11223 Chapter 6
Regulation
RA 11223 Chapter 7
Individual-based Health Services
RA 11223 Sec 18
Population Coverage
RA 11223 Sec 5
Service Coverage
RA 11223 Sec 6
Geographically Isolated and Disadvantaged (GIDA)
Refer to barangays specifically disadvantaged due to the presence of both physical and socio-economic factors. The terms GIDA, unserved and underserved areas are used interchangeably in these Rules.
Population-based Health Services (RA 11223 Sec 17)
Refer to interventions such as health promotion, disease surveillance, and vector control, which have population groups as recipients.
Individual-based Health Services
Refer to services which can be accessed within a health care facility or remotely through the use of digital technologies for health, that can be definitively traced back to one (1) recipient, has limited effect at a population level and does not alter the underlying cause of illness such as ambulatory and inpatient care, medicines, laboratory tests and procedures, among others.
Primary care worker
Refers to a health care worker, who may be a health professional or community health worker/volunteer, certified by DOH to provide primary care services.
Primary Care Provider (PCP)
Refers to a health care worker, with defined competencies, who has received certification in primary care as determined by DOH or any health institution that is licensed and certified by the DOH.
Administrative Order No. 2014-0046
The DOH issued ____________ promoting the establishment of Service Delivery Networks (SDNs) to efficiently and effectively cover the health needs of the population, particularly identified priority groups, for UHC programmes and projects.
Administrative Order No. 2014-0046
The DOH issued _____________ promoting the establishment of Service Delivery Networks (SDNs) to efficiently and effectively cover the health needs of the population, particularly identified priority groups, for UHC programmes and projects.
Repository of the data collected; manager of the registry
The DOH shall determine the human resources for health data required for the national health workforce registry, and act as a ___________ and__________.
Processing of applications; Issuance of License to Operate and Certificate of Accreditation
The DOH shall develop a system to prioritize the _____________ and ____________for health facilities in these areas.
Preferential licensing of health facilities; contracting of health services
The DOH shall develop the framework and guidelines on appropriate service capability in underserved and unserved areas, considering complementary infrastructure, equipment and bed capacity, and number of health care professionals for purposes of ____________ and ___________.
Geographically Isolated and Disadvantaged (GIDA)
The DOH shall develop the guidelines for identifying _______________ barangays and update the list of underserved and unserved areas annually.
Province-wide and City-wide
The DOH shall endeavor to contract _______________ and ____________ health systems, through a legal instrument to ensure shared responsibilities and accountabilities among members of the health system for the delivery of population-based health services including those that impact on the social determinants of health.
1. Financing capital investments 2. Human resources for health capacity building 3.Health systems development
The DOH shall finance population-based health services and provide support to complement local government resources for health in the following activities (but are not limited to):
Licensing for Primary Care Facilities and Stand-Alone Health Facilities
The DOH shall institute a responsive licensing and regulatory system for stand-alone health facilities, including those providing ambulatory and primary care services, and other modes of health service provision such as, but not limited to, mobile health services and digital technologies for health, subject to the appropriate regulatory instruments.
3 years
The DOH shall issue a License to Operate (LTO) and Certificate of Accreditation, as appropriate, to these facilities that shall be valid for at least ______ years, unless otherwise provided by laws and issuances and shall be independent of permits, registrations, and accreditations issued by other government offices.
Generic drugs
The DOH shall issue a list of _____________ in the primary care facilities (PCF) with their corresponding fair prices.
Framework Contracting of Drugs, Medical Devices and Supplies
The DOH shall promulgate guidelines and procedures in implementing framework contracting on drugs, medical devices and supplies.
Geographically Isolated and Disadvantaged (GIDA)
The DOH, PhilHealth and LGUs shall prioritize _____________ in the provision of assistance and support to ensure equitable distribution of health services and benefits:
1. HMOs and life and non-life PHIs shall cover the cost of amenities and other healthcare goods and services that are not covered by PhilHealth subject to the contractual obligations entered into by the member with HMOs and life and non- life private health insurance 2. HMOs, life and non-life PHIs shall duly submit health and health-related data in aid of developing policies, standards, and plans.
The DOH, PhilHealth, HMOs, and life and non-life PHIs, in consultation with the Insurance Commission, shall establish a coordination mechanism, and develop standards, policies and plans that complement the NHIP's benefit schedule, with the following as minimum requirements:
Clinical Practice Guidelines (CPGs)
The DOH, in cooperation with professional societies and the academe, shall set standards for clinical care through the development, appraisal, and use of ______________ based on best evidence, to assist practitioners in clinical decision-making.
Financing of Health Services (RA 11223 Sec 7, Sec 17 and Sec 18)
The DOH, in coordination with PhilHealth, Department of Budget and Management (DBM) and the Department of the Interior and Local Government (DILG), in consultation with LGUs and health care providers and partners, shall identify the milestones for the transition of other sources of financing of health facilities to improve the prospective PhilHealth payment mechanism.
1. Assurance of member access to all levels of the health care provider networks, including use of digital technologies for health 2. A primary care provider network, linked to secondary and/or tertiary care providers; Provided, That hospitals shall focus on providing specialist outpatient services, except in selected cases such as, but not limited to, gaps in the provision of primary care services and where proximity is a concern, subject to issuance of guidelines by DOH and PhilHealth 3. A patient navigation and coordination system that ensures a continuum of appropriate and coordinated care from primary to tertiary services, and back to primary care 4. Patient records management system, including electronic health records, that ensures records are accessible by all facilities or providers within the health care provider networks or among other facilities as necessary 5. Provider payment mechanism based on the
The contracted networks shall provide individual-based primary to tertiary health care services with the following minimum components:
1. Achieving universal and sustainable Philhealth membership 2. Upgrading and modernizing government health facilities through Health Facilities Enhancement Program (HFEP) 3. Fortifying efforts to achieve the Millennium Development Goal (MDG) targets
The government carried out its health reform initiatives through UHC by using three (3) key strategies.
Responsiveness to Magnitude, Severity, and Equity
The health interventions must address the top medical conditions that place the heaviest burden on the population, including dimensions of magnitude or the number of people affected by a health problem, and severity or health loss by an individual as a result of disease, such as death, handicap, disability or pain, and conditions of the poorest and most vulnerable population.
Affordability and Viability
The interventions must be affordable, and the cost thereof must be viable to the financing agents.
Cost-effectiveness
The interventions must provide overall health gain to the health system and outweigh the opportunity costs of funding drug and technology.
Household Financial Impact
The interventions must reduce out-of-pocket (OOP) expenses. Interventions must have economic studies and cost-of-illness studies to satisfy this criterion.
Licensing for Primary Care Facilities and Stand-Alone Health Facilities
The mandate and enforcement mechanisms of DOH to regulate health facilities and services shall be expanded and strengthened. For this purpose, the DOH shall establish line regulatory units up to the regional level to harmonize and enforce licensing standards; and shall allocate funds and resources to support such regulatory mandate.
1. Human resource management and development systems 2. Salaries, benefits, and incentives 3. Occupational health and safety
The mechanism of the national health workforce support system includes:
Universal Health Care (UHC)
The optimization of the six (6) critical instruments or building blocks has been identified as the key to the attainment off the three (3) strategic thrusts.
1. large number of deaths in the affected population 2. Large number of serious injuries or long - term disabilities in the affected population 3. Widespread exposure to an infectious or toxic agent that poses a significant risk of substantial harm to a large number of people in the affected population 4. International exposure to an infectious or toxic agent that poses a significant risk to the health of citizens of other countries 5. Trade and travel restrictions
The presence or impending danger of a sickness or health condition triggered by the preceding question increases the likelihood of any of the following:
PhilHealth
The published price reference indices shall guide ______________ in setting payment rates for drugs, medical devices and supplies for its contracted healthcare providers.
Population-based and individual-based health services
These health services shall be subject to assessments by the DOH in determining the most efficient financing mechanism.
Tax-deductible business expense
This is a _______________ and the government does not treat the health insurance fringe benefit as taxable income to the employee. Therefore, the government is in essence subsidizing employer-sponsored health insurance.
February 20, 2019
When did President Duterte signed the RA11223 Universal Health Care Act?
President Rodrigo Duterte
Who signed the RA11223 Universal Health Care Act?
2 years; comprehensive outpatient benefit
Within ______________ years from the effectivity of the Act (2020), PhilHealth shall implement a __________________, including outpatient drug benefit and emergency medical services in accordance with the recommendation of HTAC.
Department of Health (DOH)
[Health Technology Assessment RA 11223 Sec 34] Shall lead the health sector in the institutionalization of the HTA process as a fair and transparent priority setting mechanism that shall be recommendatory to the PhilHealth for the development of policies and programs, regulation, and the determination of a range of entitlements such as drugs, medicines, pharmaceutical products, and other devices, procedures and services.
Health Technology Assessment Council (HTAC) (RA 11223 Sec 34)
[RA 11223 Sec 34] For nondrug interventions and technologies where clinical trials are not possible or practical to conduct (e.g., surgical and medical procedures, medical device), the ________________ shall make use of the best available source of objective evidence, including, but not limited to, observational studies and real world evidence. The interventions must also not pose any harm to the users and health care providers that would outweigh the benefits they provide.
NGAs; LGUs; international health partners
__________, __________, __________, and other stakeholders shall adhere to the UHC priorities set by DOH and ensure complementation in health financing.
Healthcare providers; facilities
___________ and ___________ shall be required to make readily accessible to the public and patients and submit to DOH and PhilHealth, all pertinent, relevant, and up to-date information regarding the prices of health services, and all goods and services being offered.
PhilHealth
___________ shall prescribe the standards and requirements for third party accreditation mechanism. These may be used as basis for granting incentives to healthcare providers to be identifies by PhilHealth
