DEVELOPING POLICY RECOMMENDATIONS FOR IMPLEMENTATION OF THE

PHIC HYPERTENSION BENEFIT PACKAGE

Noel L. Espallardo, MD, MScClinical Associate Professor

UP College of Medicine and Philippine General Hospital

Burden of Illness due to Hypertension

• Complications are leading causes of mortality and morbidity

• Expensive hospitalizations • Long term need for medications and care giving

• Around 10.5 million Filipinos are hypertensive and only 13% are adequately controlled

(PHA, 2007)

PHIC Claims due to Hypertension

• US $56 million for 446,064 hospitalizations for hypertension-related diagnoses between July 2002 and December 2005

(PHIC, 2009)

• Reasons for hospital admission– 42% of admissions were for essential or secondary

hypertension– 19% for hypertensive heart or renal disease– 39% for other consequences of untreated

hypertension

Coverage for Outpatient Treatment

• Uninsured "patients" had only a 13% success rate when considering out-of-pocket payment limitations

(Blanchard, 2008)

• Health insurance coverage benefits the younger and older adults regardless of the drug class prescribed

(Blood Pressure Lowering Treatment Trialists' Collaboration, 2008)

Challenge to PHIC

• Impact to the financial state of PHIC

• This challenge can be approach by adopting several principles– cost-effective services for hypertensive patients – health services aligned with the available

resources– stewards of public fund

Objective

• Develop policy recommendations for implementation of PHIC outpatient benefit package for hypertension

Study Design

• Cross-sectional design and involved a mixture of both quantitative and qualitative methodologies (Antique, Capiz, Iloilo and Southern Leyte)

• Four phases– Analysis of PHIC paid claims database for the fiscal

years 2005-2007– Semi-structured interview of stakeholders– Document reviews – Policy workshop

Results: PHIC Reimbursements

• Iloilo – P 1.3 billion for 153,794 claims of which P 123

million were for hypertension and its related diagnosis at P 8,135 per claim

• Capiz at P 6,000.00 per claim

• Antique at Php 4,782.00 per claim

• Southern Leyte at P 2,251.20 per claim.

Health Seeking Behavior of PHIC Members

• RHU consultation preference– 93% of sponsored members– 35% of employed members – 63% individually paying members

• Private physicians– employed members and individually paying

members

Consultation Process

• 21% having their own apparatus while only 10% are monitored in the private clinics

• Commonly prescribed drug– Metoprolol– Nifedipine– Clonidine– Amlodipine

Outpatient Benefit for Hypertension

• The overall objective of this benefit package is to decrease the burden of illness to the society that is caused by hypertension and its complications.

• This will be achieved specifically by:– Enhancing and expanding access– Decreasing the financial burden– Preventing hospital admissions– Improving utilization of the PHIC SP program

Who Should Be Covered

• PHIC Sponsored Program – giving them priority will give them financial

protection to the burden of daily treatment

• Expansion to other sectors can be done once PHIC has accumulated enough experience for efficient and smooth implementation of the benefit package

Components

• Component 1 - Outpatient consultations

– Screening and diagnosis– Face to face and one-on-one health education– Lifestyle modification seminars and skills training

for patients

Components

• Component 2 – Laboratory Screening

– The following laboratory tests should be done at appropriate intervals but no more than 2 times a year:

• FBS• Urinalysis

Components

• Component 3 – Medicines

– Medicines covered are the first line anti-hypertensives

• Metoprolol• Captopril• Thiazide• Amlodipine

Strategies for Implementation

Components RHU/LGU DOH PHICConsultationScreening and diagnosis

Health education and counselling

Lifestyle change seminars

Consultation services will be provided by the RHU staff

Salaries of the staff providing the services will be shouldered by LGU

DOH will provide training and technical assistance to RHU staff

DOH will partner with specialty societies in developing training programs

PHIC will provide subsidy through its SP capitation

PHIC will develop monitoring mechanisms for incentives and contracting

Strategies for Implementation

Components RHU/LGU DOH PHICLaboratory The basic

laboratory will be shouldered by RHU/LGU as part of the capitation fund

The other laboratory will be shouldered by LGU or minimal co-payment by the patient

PHIC will provide subsidy through its SP capitation

Strategies for Implementation

Components RHU/LGU DOH PHICMedicines The basic

medicines will be purchased by LGU and reimbursed to PHIC

Other medicines will be shouldered by LGU or minimal co-payment by the patient

DOH will facilitate access by RHU/LGU to DOH P 100 program

PHIC will setup mechanisms for subsidy to medicines

Private pharmacy involvement

Cost to PHIC

2009 2010 2011 2012 2013PHIC SP Members 19,800,000 20,790,000 21,829,500 22,920,975 24,067,024

Hypertensive Patients 483,912 508,108 533,513 560,189 588,198

Consultation services Cost to LGU Cost to LGU Cost to LGU Cost to LGU Cost to LGULaboratory services Cost to LGU Cost to LGU Cost to LGU Cost to LGU Cost to LGU

DOH P 100 580,694,400 609,729,600 640,215,600 672,226,800 705,837,600

Drugs in Private Pharmacy

883,139,400 927,297,100 973,661,225 1,022,344,925 1,073,461,350

Thank You Very Much