synopsis of the PhilHealth Catastrophic Benet: Case Type Z

WHAT IS A CATASTROPHIC ILLNESS? WHY THE NEED FOR A BENEFIT PACKAGE?

THE Z BENEFIT PACKAGE OF PHILHEALTH

MEDICAL CATASTROPHE

A condition or disease state that can lead to disability or death.

ECONOMIC CATASTROPHE

When the cost of care is too high that patients affected are pushed into poverty.

CATASTROPHIC ILLNESS

For the purpose of benets development, dened as both medically and economically catastrophic.

Yearly, the Philippine Health Insurance Corporation (PhilHealth) pays about 7 billion in premium payments for catastrophic diseases categorized as type C and D. However, support value remains low. Thus, in line with its goals of nancial risk protection for all Filipinos, PhilHealth is developing an initial set of benets that comprehensively cover catastrophic conditions.

7 billion

WHAT ARE THE DIFFICULTIES IN DEVELOPING THE BENEFIT PACKAGE? Challenges encountered during benets development are:

WHAT WERE THE PROPOSED AND APPROVED INITIAL BENEFITS? Based on the following premises:

Lack of reliable information on incidence rates

Limited nancial resources of the National Health Insurance Program

The country has the science and facilities to address the conditions considered catastrophic

Identied conditions have high or acceptable survival rates after treatment with locally-validated protocols

Limited availability of equipment and facilities, and of healthcare workers with the specialized skills and knowledge necessary to providing the services required to achieve the desired health outcomes.

PhilHealth can negotiate for No Balance Billing for sponsored members (those with no capacity to pay) and a xed co-payment for non-sponsored program members (those with capacity to pay).

WHAT WERE THE PROPOSED AND APPROVED INITIAL BENEFITS?

The following are the rst set of PhilHealth catastrophic benets, with the corresponding package cost and entitled services
Disease/Condition Cost

Entitled Services

EARLY STAGE BREAST CANCER (Stage 0-3a)

PHP 100,000

Cardiopulmonary (CP) clearance and surgery, the whole session of chemotherapy, and radiation therapy (if necessary)

Standard risk CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA ALL

PHP 210,000 in 3 years

Complete course of chemotherapy, essential laboratories, and blood support

Low to intermediate risk PROSTATE CANCER

PHP 100,000

CP clearance and surgery and other laboratories, hormone therapy or radiation treatment (if indicated only)

WHY THE AFOREMENTIONED DISEASES AND WHY ONLY THOSE SPECIFIC STAGES? WHY DO WE NEED THE CO PAY?
As the fund manager of the National Health Insurance Program, PhilHealth must efciently and effectively use the funds to cover the most number of beneciaries. As such, only diseases that have around 80% chance of 5-year survival have been included in the initial set of benets. In the next months, PhilHealth shall continue to expand the diseases covered under this benet package. Since the contracted facilities must ensure No Balance Billing for all sponsored program members, they will need to recoup any losses they might encounter. As such, for non-sponsored program members, facilities shall be allowed to change xed negotiated rate as co-payment.

HOW MUCH WILL THE ENTIRE COVERAGE OF THE SAID ILLNESSES COST PHILHEALTH?
PhilHealths reserve funds have gone down to Case Type Z shall cost the corporation

from 107 billion pesos 2 years ago

90 billion

which will be charged to the reserve funds.

3 billion

HOW MUCH WILL THE ENTIRE COVERAGE OF THE SAID ILLNESSES COST PHILHEALTH?
Breast Cancer Childhood Leukemia Prostate Cancer COST PER PACKAGE Php100,000 Php210,000 Php100,000 TARGET NO. OF CASES 10,000 1,000 1,000 TOTAL COST Php1 billion Php210 million Php100 million

WILL THE SAID BENEFIT BE AVAILABLE IN ALL PHILHEALTH ACCREDITED INSTITUTIONAL HEALTHCARE PROVIDERS IHCPS ?
Since not all IHCPs have the heathcare workers and the equipment esssential to providing specialized care to cancer and transplant patients, the said benets will not be available in all IHCPs. Moreover, not all IHCPs are willing to apply NBB for the sponsored members or negotiate co-payment at a xed rate not exceeding the package cost.
INSTITUTIONAL HEALTH CARE PROVIDERS IHCPS

Thus, in the initial implementation,

22 GOVERNMENT HOSPITALS

have been contracted to provide the services. Eventually, this set of providers shall be expanded.

WHO CAN AVAIL?

Any and all eligible PhilHealth members or their qualied dependents that shall be admitted to the designated rooms in the identied hospitals may avail.
WHY IS IT CALLED THE Z BENEFIT?
In the alphabet of PhilHealth case types for diseases, disease conditions are classied from type A to D.

The simplest and cheapest conditions.

The more severe and costly conditions.

Thus, case type Z describes the disease conditions at the far end of the spectrum. However, as mentioned, the set of benets for Case Type Z will highlight the need for continuity of care and better outcomes.