Health Financing and Governance – ROJoson’s TPORs

September 27, 2017

I was asked these questions today.  I gave my Thoughts, Perceptions, Opinions, and Recommendations.

  1. What does quality improvement in health care mean to you?

Improvement in quality in health care where quality is defined with the following parameters: accessible, timely, rational, cost-effective, cost-efficient, and safe medical care, whether in the hospital, clinic or any health care institution.

  1. Which institution or organization do you think has the primary mandate is to oversee the quality of health care in the Philippines?

Department of Health has the primary mandate to oversee the quality of health care in the Philippines.

  1. In your view, who are the “champions” for improving the quality of healthcare in the Philippines? Why/how so?

Starting with the Secretary of Health – as its office has the primary mandate to oversee the quality of health care in the Philippines.

Then, the owners and administrators of all health care institutions, all kinds, both public and private, as they are expected to provide quality health care to all their clients.

All these champions should be aligned and coordinated in the goals in providing quality health care in the Philippines (using an agreed definition of quality health care).

  1. Are there any laws or regulations about health care quality that you know about?

Yes, there are.

Starting with the Philippine Medical Act, Philippine Nursing Act, Philippine Pharmacy Act, and other Acts for the health care professionals.

Laws protecting the patients such as no-deposit law, confidentiality, Fire Codes, disaster drills, etc.

Department of Health Administrative orders.

  1. Can you tell us a little more about the development of the guiding national strategy or plan for quality in health care in the Philippines?

Essential steps in the development of the guiding national strategy or plan for quality in health care in the Philippines:

  • Start with parameters, criteria and indicators of quality health care in the Philippines that are formulated by the Department of Health and supported by all health care organizations in the Philippines.
  • Ask all health care organizations in the Philippines to support the program to provide quality health care in the Philippines.
  • Provide assistance, in terms of training and other resources, on quality health care to all health care organizations.
  • Monitor the outcomes of the implementation of the health care organizations on providing quality health care to their clients through an external independent audit done by the Department of Health or its representative.
  • Provide recognitions and awards to health care organizations with performance excellence.
  1. Sometimes it is beneficial to explore other countries’ experiences with major policy initiatives, like health financing reforms or quality improvement initiatives. To what extent do you think other countries’ experiences influenced the Philippines’ policy reforms around health care quality?

The Philippines is adopting and adapting the experiences of other countries like the case rates, relative values schemes, Health Maintenance Organizations, National Health Insurance Program, the PhilHealth Benchbook adopting and adapting to Joint Commission International Standards, Clinical Practice Guidelines, evidence-based medicines, etc.

  1. To what extent do health financing institutions apply quality criteria to determine which health care providers can receive payments from them?

In the Philippines, there are two prominent health care financing schemes, namely, the PhilHealth and the Health Maintenance Organizations.  Only PhilHealth is clear on applying quality criteria to determine which health care providers can receive payments from it.  It is using the PhilHealth Benchbook as a basis for accreditation and this Benchbook contains quality and safe patient care standards.

The Health Maintenance Organizations does not require accreditation of health care organizations and their health care providers using quality and safe standards like the one of PhilHealth Benchbook.  It is enough that the health care organizations have license to operate from the Department of Health and the health care providers have licenses to practice medicine in the Philippines.

  1. We know that the Philippines uses mechanisms like [e.g., salaries, capitation, and DRGs] to reimburse its providers. Now we want to better understand how these payments may or may not be adjusted for quality.

These payments may be adjusted for quality health care.

Speaking of case rates of PhilHealth, PhilHealth has to make sure that the case rates are formulated with transparent, flexible and sound bases – medical conditions, usual recommended cost-effective management and cost of the management.   The latter processes should be made known to the health care institutions.  The case rates should be updated every so often and as indicated.

The health care providers should be oriented and convinced to stick to the clinical practice guidelines and clinical pathways that are being recommended in the implementation of the case rates.

  1. We know that the Philippines has a standard benefits package in place that specifies which services are eligible for reimbursement. Now we want to better understand how this benefits package may or may not be adjusted for quality.

These benefit packages may be adjusted for quality health care.

Just like in the case rates, PhilHealth has to make sure that the benefit packages are formulated with transparent, flexible and sound bases – medical conditions, usual recommended cost-effective management and cost of the management.   The latter processes should be made known to the health care institutions.  The benefit packages should be updated every so often and as indicated.

The health care providers should be oriented and convinced to stick to the clinical practice guidelines and clinical pathways that are being recommended in the implementation of the benefit packages

  1. How are patients encouraged to select higher quality providers? How can they figure out which providers are better quality?

In the Philippines, patients usually to the physicians they trust wherever the latter are.  Secondary is the reputation of the health care institutions, including whether it is PhilHealth-accredited, ISO-accredited, Joint Commission International-accredited, or Accreditation Canada International-accredited.

How are patients encouraged to select higher quality providers? Either through publication or making known of the external quality accreditation of the hospitals or through the hospitals’ own marketing and public relations strategies.

How they figure out which providers are better quality?  This is through the personal patient experience.

  1. Do health financing institutions make direct investments in quality improvement? Is that considered part of their purview, or does another institution have responsibility for this?

In the Philippines, there are two prominent health care financing schemes, namely, the PhilHealth and the Health Maintenance Organizations.  They don’t do direct investment in quality improvement.  Only PhilHealth makes indirect investments in quality improvement as it requires all health care organizations which want to be accredited with it to comply with the quality and safe patient care standards contained in the PhilHealth Benchbook.  This indirect investment is part of the purview of the PhilHealth (as mandated by law – Philippine National Health Insurance Program).

The Health Maintenance Organizations do not even make indirect investments in quality improvement. They just pay the allowable maximum coverage for expenses incurred by a patient to the health care organizations and health care providers.  The Health Maintenance Organizations do not usually monitor the outcomes of care of patient-clients.

 

  1. Do health financing institutions provide non-financial incentives to encourage quality improvement (e.g., public recognition or awards to providers or facilities for high quality of care)?

In the Philippines, there are two prominent health care financing schemes, namely, the PhilHealth and the Health Maintenance Organizations.  Only PhilHealth provide non-financial incentive to encourage quality improvement.  PhilHealth at least attempted in the past  giving recognition to Center of Quality, Center of Safety, and Center of Excellence.  It has shelved this public recognition and award.  I think in 2018, with the PhilHealth Benchbook 2nd edition, it will categorize hospitals into basic and advanced accreditation.

The Health Maintenance Organizations do not have non-financial incentives schemes.

  1. In your opinion, to what extent do you feel that health financing institutions have clear roles and clear responsibilities in promoting the quality of care in your country?

In the Philippines, there are two prominent health care financing schemes, namely, the PhilHealth and the Health Maintenance Organizations.  Between the two, PhilHealth has clearer roles and responsibilities in promoting quality health care in the Philippines.  PhilHealth requires accreditation of health care organizations using standards contained in the PhilHealth Benchbook.  The standards are clear on quality and safe patient care.   Complementing the accreditation requirements, PhilHealth uses case rates to prod hospitals (especially those hospitals on No-balance-billing) to follow clinical practice guidelines and clinical pathways in the management of patients.  However, there is still a lot of improvement to be done such as requiring all hospitals, even private ones, to go on no-balance-billing and providing sound basis for the computations of the no-balance-billing.  At least, there are activities being done by PhilHealth that are more clearly observed in promoting quality of care in the Philippines.

The Health Maintenance Organizations does not require accreditation of health care organizations and their health care providers using quality and safe standards like the one of PhilHealth Benchbook.  It is enough that the health care organizations have license to operate from the Department of Health and the health care providers have licenses to practice medicine in the Philippines.  Whatever expenses incurred by a patient are paid (within the allowable maximum benefit) to the health care organizations and health care providers.  The Health Maintenance Organizations do not usually monitor the outcomes of care of patient-clients.

  1. Based on your experience here in the Philippines, what would you recommend to other countries about how to involve health financing institutions in influencing the quality of care provided?

How to involve health financing institutions in influencing the quality of care provided – Have the health financing institutions come out with packages like the case rates but make sure that the case rates are formulated with transparent, flexible and sound bases – medical conditions, usual recommended cost-effective management and cost of the management.   The latter processes should be made known to the health care institutions.  The case rates should be updated every so often and as indicated.


ROJ@17sept27

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Clinical summary, hospital medical abstract, etc.

In a hospital inpatient setting, physicians often encounter patients requesting for certification, clinical summary, hospital medical abstract, etc.

The requests usually originate from requirements from a third-party agency such as Social Security System, Philippine Charity Sweepstakes Office, another hospital where the patient intends to consult; etc.  Occasionally, a patient requests these on a personal need or want basis to be  included in his / her medical record file.

The requests are done either during confinement (or just before discharge) or after discharge from the hospital.

Hospitals have various terms for all these requests for patient information to be accomplished by the attending physicians.  Internet surfing shows the following terms or phrases that are being used:

  • Clinical Summary / Clinical Abstract
  • Discharge Summary / Discharge Abstract
  • Hospital Abstract / Medical Abstract

Some hospitals use “Clinical Summary / Abstract” for patients still confined in the hospital and “Hospital / Medical Abstract,” after discharge.

Some hospitals use “Discharge Summary / Abstract” when issued just before discharge and “Clinical Summary / Abstract” issued while patient is still confined and not yet for discharge (patient needs this at this time per requirement of a third party).

Some hospitals use “Hospital Abstract” instead of “Medical Abstract” to differentiate it from the medical abstract of medical research papers.   In the Philippines, most hospitals, if not all, use “Medical Abstract” to mean “Hospital Abstract,” an abstraction of the patient’s medical records during the hospitalization.

Some hospitals have proforma template for the abovementioned documents to be accomplished by the attending physicians.  Some do not.

ROJoson’s Insights (Thoughts, Perceptions, Opinions and Recommendations):

  1. I prefer to use “Hospitalization Abstract” over “Hospital Abstract” and “Medical Abstract.”
  2. “Hospitalization Abstract” is the final document that abstracts all the medical records of the patients during their hospitalization.  It is ideally prepared after discharge but accomplished as quickly as possible after all results of diagnostic tests are in (often times patients are discharged without the results of diagnostic tests yet such as histopathologic examination and other tests whose results require days for completion).
  3. “Discharge Summary / Abstract” may be the same as the “Hospitalization Abstract” if all medical records are complete already at the time of discharge (no pending results of diagnostic tests).  “Discharge Summary / Abstract” issued at the time of discharge is converted to a “Hospitalization Abstract” if all the medical records are complete already at the time of discharge (if there is nothing to add in the “Discharge Summary / Abstract.”
  4. For patients needing a medical certification at the time they are still confined and not yet for discharge (per requirement of a third party), the term or phrase “Clinical Summary / Abstract” may be used but there must be an accompanying notation that it is not a “Discharge Summary / Abstract” and “Hospitalization Abstract” or “Medical Abstract” and that inpatient management is still ongoing.  There must also be an emphasized notation of date of issuance of the “Clinical Summary / Abstract.”

ROJ@17sept15

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Management of Medical Sharps Wastes in Clinics

Medical sharps wastes like needles and blades should be placed immediately after use in appropriate puncture-resistant containers.

This is to avoid medical sharp injuries to the medical staff as well as to people disposing the sharp wastes.

In my clinic, I use this kind of recycled puncture-resistant containers to dispose of the used needles and blades.  Such a practice is in conformity with the requirements of PhilHealth Benchbook and other international health care standards.

IMG_5273

IMG_5271

PhilHealth Benchbook Standards:

There are programs for prevention and treatment of injuries from sharps and needles.

a. Policies and procedures for the safe disposal of used sharps and needles comply with national laws and technical requirements.

b. Sharps and needles are segregated and disposed according to regulatory and infection control standards.

c. Injuries from sharps and needles are monitored.

d. Staff are trained in preventing and treating injuries from sharps and needles.

Joint Commission International Standards:

The hospital implements practices for safe handling and disposal of sharps and needles.

1. The hospital identifies and implements practices to reduce the risk of injury and infection from the handling and management of sharps and needles.
2. Sharps and needles are collected in dedicated, closable, puncture-proof, leakproof containers that are not reused.
3. The hospital disposes of sharps and needles safely or contracts with sources that ensure the proper disposal of sharps containers in dedicated hazardous waste sites or as determined by national laws and regulations.

ROJ@17aug7

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Elements of a Management System

Always include the following elements in formulating a management system and you won’t go wrong!

  • Design and Development Plan
  • Deployment, Education and Implementation Plan
  • Evaluation and Review Plan
  • Documentation and Archiving Plan
  • Management Review Plan
  • Independent Audit Plan

ROJ@17aug4

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Patient Rights and Responsibilities – ROJMC – 2017

At ROJMC, our goal is to provide quality and safe health care to every patient.

ROJMC has formulated a set of essential (but not exclusive) patient rights and responsibilities to facilitate patient care partnership and promote patient experience.  These shall be observed for and by all patients regardless of race, culture, religion, age, sex, and socioeconomic status.

Patient rights include those actions on the part of the ROJMC that are needed to protect the basic rights of patients so that they can be provided with quality and safe health care services.

Patient responsibilities include those actions on the part of patients that are needed so that healthcare providers can provide appropriate care, make accurate and responsible care decisions, address patients’ needs, and maintain a sound and viable health care facility.

All patients have the right to:

  • Quality and safe health care in accordance with generally approved medical principles
  • Respect and dignity without discrimination
  • Participation in care decisions
  • Informed consent and informed refusal without prejudice to continuing health care
  • Second opinion from alternate health care professionals of choice
  • Privacy and confidentiality of personal information subject to applicable laws
  • Availment of benefits and privileges in accordance with government regulations
  • Complaint about the care and services provided without fear of reprisal

All patients while availing services are responsible to:

  • Provide the hospital with truthful and complete information
  • Heed hospital rules and regulations, particularly those affecting patient care, safety and conduct
  • Be active partner in regaining and maintaining health
  • Promptly settling financial obligations
  • Comply and submit documents necessary to avail of benefits (e.g., PhilHealth, Senior Citizen, Person with Disability discounts, letters of authorization for HMO and corporate account members)
  • Actively help ROJMC improve quality and safe patient care through feedback with recommendations

ROJMC shall provide general guidelines in Information, Education and Communication (IEC) materials to promote protection of patient rights and to assist patients in fulfilling their responsibilities.

 


ROJ@17jul14

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Life Expectancy – World, ASEAN, Philippines – 2015

Life expectancy

Definition: the average period that a person may expect to live.

Definition: Life expectancy equals the average number of years a person born in a given country is expected to live if mortality rates at each age were to remain steady in the future. 


WORLD

Global life expectancy for children born in 2015 was 71.4 years (73.8 years for females and 69.1 years for males), but an individual child’s outlook depends on where he or she is born.

The report shows that newborns in 29 countries – all of them high-income — have an average life expectancy of 80 years or more, while newborns in 22 others – all of them in sub-Saharan Africa — have life expectancy of less than 60 years.

With an average lifespan of 86.8 years, women in Japan can expect to live the longest. Switzerland enjoys the longest average survival for men, at 81.3 years. People in Sierra Leone have the world’s lowest life-expectancy for both sexes: 50.8 years for women and 49.3 years for men.

Women on average live longer than men.

http://www.who.int/mediacentre/news/releases/2016/health-inequalities-persist/en



ASEAN

 
ASEAN Countries

World Standing

Life Expectancy (2015)

Overall

Female

Male

Singapore

3

83.1

86.1

80.0

Brunei

39

77.7

79.2

76.3

Vietnam

56

76.0

80.7

71.3

Malaysia

67

75.0

77.3

72.7

Thailand

70

74.9

78.0

71.9

Indonesia

120

69.1

71.2

67.1

Cambodia

123

68.7

70.7

66.6

Philippines

124

68.5

72.0

65.3

Myanmar

129

66.6

68.5

64.6

Lao

137

65.7

67.2

64.1

Average

72.53 75.09 69.99


PHILIPPINES – 2015 (WHO Data)
 
Rank worldwide – No. 124
Rank in ASEAN – No. 8
 
Overall – 68.5 years
 
Female – 72.0
Male – 65.3
ROJ@17apr14
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Population – World, ASEAN, Philippines – 2017

World Population

7.5 billion (as of April 2017)

7 billion (2011)

Forecast:

8 billion by 2023

10 billion by 2057

Population in the world is currently (2017) growing at a rate of around 1.11% per year (down from 1.13% in 2016). The current average population change is estimated at around 80 million per year.

Annual growth rate reached its peak in the late 1960s, when it was at 2% and above. The rate of increase has therefore almost halved since its peak of 2.19 percent, which was reached in 1963.

The annual growth rate is currently declining and is projected to continue to decline in the coming years. Currently, it is estimated that it will become less than 1% by 2020 and less than 0.5% by 2050.



ASEAN Population

Founded in 1967, ASEAN encompasses Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam

Approximately 646 million people, 8.6% of the world’s population.

ASEAN Countries Population (April 2017)
Indonesia 263,510,146
Philippines 103,796,832
Vietnam 95,414,640
Thailand 68,297,547
Myanmar 54,836,483
Malaysia 31,164,177
Cambodia 16,076,370
Laos 7,037,521
Singapore 5,784,538
Brunei 434,448
Total 646,352,702

http://www.worldometers.info/population/countries-in-asia-by-population/



Philippines

Philippines (103,796,832 – 104 million) – No. 13 in the world standing; No. 2 in ASEAN

Year

Population

Yearly % Change

Yearly Change

2017

103,796,832

1.51 %

1,546,699

2016

102,250,133

1.54 %

1,550,738

2015

100,699,395

1.6 %

1,532,099

2010

93,038,902

1.55 %

1,379,506

2005

86,141,373

2.02 %

1,641,825

2000

77,932,247

2.22 %

1,619,307

Sex ratio: approximately 1:1

ROJ@17apr14

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