Managed Care

THE DOCTOR IN MANAGED CARE ORGANIZATION

ALEJANDRO V. PINEDA JR., MD, DFM, FPAFP RAFAEL P. BANTAYAN JR., MD, DFM, FPAFP

The Philippine Health Care Delivery System Structure of the Health Care Delivery System • • •

Government Sector Social/Insurance Private Sector

Government Sector

• • • •

DOH RHU Government Hospitals Tertiary Care Medical Centers

Social Insurance

• PhilHealth Philippine Health Insurance Commission • ECC Employees Compensation Commission

Private Sector

• • • • •

Out of pocket (Private Practice) Health Insurance Managed Care (HMOs) Employer’s Based Health Care Program Schools

Managed Care

“An organized system of health care delivery, offering a comprehensive set of benefits, in which members are voluntarily enrolled, and paying for a fixed, prepaid period.”

Types of Managed Care • HMO (Health Maintenance Organization) • PPO (Preferred Providers Organization) • IPA (Independent Practice Association) • HPO (Hospital Providers

Structural Classification of HMO’s

1. Staff Model 2. Group Model 3. Combination

Classification of HMO’s as Per Ownership

1. Investor–Based HMO’s 2. Community–Based HMO’s 3. Cooperative–Based HMO’s

HMO’s in the Philippines (as of October 2003) • • • • • • • • •

PhilamCare Medicard Maxicare HMI SPCare Fortune Care StarCare Blue Cross Medserv

HMO’s in the Philippines (as of October 2003) • • • • • • • • •

I.Care Ayala Care HPPI Pryce Care Caritas Health Shield Cocolife CAP Health IMS/Wealth Care MEDOCare

Generic Structure of an HMO

Frontline Divisions Medical Services Marketing & Sales

Support Division/Department Administration Finance, Treasury, HRRD, MS, Actuarial

Membership Services

Basic Misconceptions

1. It is not a Health Insurance. 3. It is not a Pre-Need Insurance.

Important Differences Between an HMO and Health Insurance FEATURES

HMO

INSURANCE

Method of Payment

Direct settlement Reimbursement

Scope of Services

More comprehensive

Limited

Choice of Hospital and Physicians

Limited

Freedom of choice

Membership Fee

Higher

Lower

Cost Effectiveness Present & Quality Assurance Mechanisms

Not present

Supervising Government Agency

OIC

DOH

HMO Basic Health Care Package

I. Out-Patient Benefits II. In-Patients Benefits III. Emergency Care Benefits

Benefits Package 1. 2. 3. 4. 5.

Preventive Health Care Out Patient Services In Patient Services Emergency Care Optional Benefits • Dental • • • •

Maternity Prescription Medicine Term Insurance Annual P.E./ Pre-Employment

Challenges/Problems Of Hmo’s • Difficult relationship with medical providers • Lack of support/incentives from the government • Uncontrolled competition • Market competition • Lack of standards for cost quality care

Health Sector Reforms Initiative Of DOH/PHIC • Increased funding by health insurance • Expand coverage of PHIC to indigent population • Increased benefit coverage • Reference pricing for drugs/hospital charges • Use of national drug formulary • Nationwide RVS

FUTURE DIRECTIONS  Continued

shift to manage care by companies  NHIC adopting managed care features to control cost quality  Population covered by health insurance will increase  HMO/Provider Partnering  Consolidation of the Industry  Benign Governance

TH AN K Y OU V ERY MU CH & GOOD D AY!