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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