1.health financing 101 Dr. Caballes

2,019 views

Published on

ALVIN B. CABALLES, MD, MDE, MPP

CURRICULUM VITAE

PERSONAL DATA
Name: Caballes, Alvin Bernardo
Position: Associate Professor, College of Medicine, University of the Philippines
Cell No.: 09217148829
Office: Social Medicine Unit, U.P. College of Medicine, P. Gil St., Manila (4006658); Rm. 519 Medical Arts Building, St. Luke’s Medical Center (7231021)
Email: abchealth@ymail.com, abcmd@alumni.princeton.edu

ACADEMIC/TRAINING RECORD
College: University of the Philippines, Diliman (B.S. Biology, 1981, cum laude)
Medical School: College of Medicine, University of the Philippines (graduated 1985, 11th in class; Class President, 1985; Class Award in Leadership, 1985)
Post-Graduate Training:
Internship: Philippine General Hospital (1986-87; Medical Student Council Representative; Outstanding Intern in Pediatrics)
Residency: Pediatric Surgery, Department of Surgery, Philippine General Hospital (1987-92; Chief Resident, Department of Surgery, 1991)
Masteral: Development Economics (University of the Philippines, 2002)
Public Policy, with Certificate in Health Policy (Princeton University, 2008)
Fellowship/Others: Transplantation, University of Miami; 1995; GB Ong Fellow, University of Hong Kong, 2003

CERTIFICATION
Physician’s Licensure Examination - passed, 1986
U.S. Medical Licensure Examinations I & II - passed, 1994
Diplomate Examinations, Philippine Society of Pediatric Surgeons - passed, 1993

OTHER PROFESSIONAL CITATIONS
Fellow, Philippine Society of Pediatric Surgeons, 1996
Fellow, Philippine College of Surgeons, 1997
Eusebio Paulino Professorial Chair, UPCM, 2007

OTHER POSITIONS
Chief, Social Medicine Unit, UP College of Medicine, 2004 – present
Program Administrator, Joint UPM-UPD Bioethics Graduate Program, 2004 – present
Faculty, Department of Surgery, Philippine General Hospital, 1994 – present
Head, Division of Surgery, Philippine Children’s Medical Center, 2005 – 2007
Head, Endoscopy Unit, Philippine Children’s Medical Center, 2004 – 2007
Board Member, Philippine Board of Pediatric Surgery, 1999 – 2002
Chair, Nutrition Support Team, Philippine General Hospital, 2000 – 2003
Editor in Chief, PCS Newsletter, 2005 – 2006
Associate Editor, Philippine Journal of Surgical Specialties, 2005 – 2007

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,019
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
345
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

1.health financing 101 Dr. Caballes

  1. 1. Medical History Management Medical Economics Bioethics Medical Jurisprudence Rights Medical Anthropology
  2. 2. Risks of Surgical Conditions: Occurrence and Cost
  3. 3. Introducing Medical Students to Health Financing
  4. 4. Risks of Surgical Conditions: Occurrence and Cost
  5. 5. Average Family Hospitalization Expenses*** P 5,874 Poverty Threshold**** P 4,835 Percentage of Families Below Threshold**** 27.5 % *** FIES, 2000 **** NSCB, 2000
  6. 6. NDHS, 2008
  7. 8. Concepts & Contexts ALVIN B. CABALLES, MD
  8. 9. Salient Points <ul><li>Sourcing </li></ul><ul><li>Strategies </li></ul><ul><li>Scenarios </li></ul><ul><li>Synergies </li></ul>ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010
  9. 10. Sourcing Strategies Scenarios Synergies ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010
  10. 11. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 So why not just pay out-of-pocket? REMEMBER? Health services (and supplies) can be expensive (relative or absolute terms) Services needs to be paid, or else these will be under-provided Catastrophic health expenditures can lead to (further) financial ruin (& even worse health) Sourcing Strategies Scenarios Synergies
  11. 12. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 More on “Catastrophic Health Expenditures” Sourcing Strategies Scenarios Synergies
  12. 13. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 More on “Catastrophic Health Expenditures” Sourcing Strategies Scenarios Synergies
  13. 14. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 More on “Catastrophic Health Expenditures” Sourcing Strategies Scenarios Synergies
  14. 15. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Pooling Risks: Health & Financial Sourcing Strategies Scenarios Synergies
  15. 16. GOVERNMENT REVENUES ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Pooling Options Sourcing Strategies Scenarios Synergies Characteristics <ul><li>raised from general taxes/duties; may be done at different government levels (e.g., local taxes) </li></ul><ul><li>requires administrative capacity </li></ul><ul><li>may be vertically redistributive (e.g., subsidized health expenses for the poor) </li></ul>Advantages <ul><li>potential to generate most resources </li></ul>Disadvantages <ul><ul><ul><ul><li>sensitive to economic downturns </li></ul></ul></ul></ul><ul><ul><ul><ul><li>horizontal equity often difficult (e.g., which sector assumes more tax burden vs. benefits) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>taxes diminish wages/production </li></ul></ul></ul></ul><ul><ul><ul><ul><li>undermined by bad governance and widespread tax evasion </li></ul></ul></ul></ul>
  16. 17. PRIVATE INSURANCE ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Pooling Options Sourcing Strategies Scenarios Synergies Characteristics <ul><ul><ul><ul><li>insurance purchased voluntarily </li></ul></ul></ul></ul><ul><ul><ul><ul><li>premium payments adjusted for risks </li></ul></ul></ul></ul>Advantages <ul><ul><ul><ul><li>no “free-riders” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>free choice (of plan) </li></ul></ul></ul></ul>Disadvantages <ul><li>more limited risk pooling </li></ul><ul><li>risk selection/cream skimming </li></ul><ul><li>often regressive premium rates </li></ul><ul><li>substantial transaction costs </li></ul><ul><li>limited regulation </li></ul>
  17. 18. SOCIAL HEALTH INSURANCE ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Pooling Options Sourcing Strategies Scenarios Synergiess Characteristics <ul><ul><ul><ul><li>compulsory enrollment (for specified population) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>social compact (defined premiums and guaranteed benefits, not “welfare”) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>“ earmarked tax” (publicly administered fund designated for health goods and services) </li></ul></ul></ul></ul>Advantages <ul><ul><ul><ul><li>discrete fund purposely for health activities </li></ul></ul></ul></ul><ul><ul><ul><ul><li>greater public willingness to participate </li></ul></ul></ul></ul>Disadvantages <ul><li>similar to general revenue, but of less magnitude </li></ul>
  18. 19. Once Again… ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies Pooling Options Private/Indemnity SHI Premiums Reflects Risk/Expected Loss Based on Ability to Pay Risk Spreading Group or Community Population/ ?Generations Insurer Commercial firms Public firms Government Subsidy May be indirect (tax incentive) Often highly subsidized
  19. 20. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies Insurance Concerns Information Assymetry Moral Hazard Adverse Selection
  20. 21. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies Insurance Concerns <ul><li>While health insurance makes medical care more accessible, true costs are hidden from patients (& providers) and thus makes medical care “too affordable” </li></ul><ul><li>Mechanisms to limit utilization: </li></ul><ul><ul><li>For patients: gatekeeper, copayments </li></ul></ul><ul><ul><li>For providers: clinical pathways/CPGs, utilization reviews, capitation </li></ul></ul>
  21. 22. Philippine Trends: Total ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  22. 23. Philippine Trends: Main Sources ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  23. 24. Philippine Trends: Health Insurance ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies NDHS, 2008
  24. 25. Philippine Trends: PHIC ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  25. 26. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010
  26. 27. Demographic Transition: Double Burden ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies Preston, 1975
  27. 28. Demographic Transition: Financing Effects ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  28. 29. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  29. 30. Economic Growth & Health Financing Sustainability ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 Sourcing Strategies Scenarios Synergies
  30. 31. ALVIN B. CABALLES, MD HEALTH FINANCING SUMMIT UP Diliman 14 April 2010 TAKE HOME MESSAGES: Adequate financing is necessary not only to remedy poor health, but also to safeguard against (further) impoverishment Efficient pooling mechanisms are necessary to ensure the accessibility of essential health services especially for the poor, as well as to prevent financial ruin Adequate financing is necessary for the provision of health services, but this alone is not sufficient for ensuring the adequacy and efficiency of provision Health is not a stand alone concern
  31. 32. Thank you for being a captive-ating audience
  32. 35. Managed Care in RP <ul><li>1 st Asian country </li></ul><ul><li>started in late 1970’s </li></ul><ul><li>reached peak of 38 HMO’s in late 1990’s </li></ul><ul><li>surpassed indemnity insurance in revenues </li></ul><ul><li>2002: 29 operating HMO’s; 15 AHMOPI members </li></ul><ul><ul><li>(95% of market) </li></ul></ul>
  33. 36. Indemnity Health Insurance <ul><li>“ casualty insurance” </li></ul><ul><li>Reimbursement for certain expenses or for loss of income </li></ul><ul><li>Consumer choice not very restricted </li></ul><ul><li>Encourages over-utilization of medical care and increased expenses </li></ul><ul><li>“ traditional” indemnity insurance losing market dominance </li></ul>
  34. 37. Managed Care Plans <ul><li>MCP firm </li></ul><ul><ul><li>involved in both financing & actual utilization of health service </li></ul></ul><ul><ul><li>acts as patient’s “agent”, to get better care at lower prices </li></ul></ul><ul><ul><li>has to earn (even if non-profit), therefore has all the incentive to provide quality care at least cost </li></ul></ul>
  35. 38. Types of MCP Firms <ul><li>Health Maintenance Organizations (HMO) </li></ul><ul><li>Preferred Provider Organizations (PPO) </li></ul><ul><li>Point of Service Plans (POS) </li></ul><ul><li>Administrative Service Only (ASO) </li></ul><ul><li>Minimum Premium Plans (MPP) </li></ul>
  36. 39. Health Management Organization <ul><ul><li>Has network of accredited providers </li></ul></ul><ul><ul><li>“ Gatekeeper” for care/referrals </li></ul></ul><ul><ul><li>Adheres to Clinical Practice Guidelines </li></ul></ul><ul><ul><li>Only care given within network paid </li></ul></ul><ul><ul><li>Closed-panel: firms where all care is in-house </li></ul></ul>
  37. 40. Preferred Provider Organization <ul><li>“ middleman” between purchaser and provider, more manager than financier </li></ul><ul><li>also adheres to utilization controls </li></ul><ul><li>providers paid on discounted rates or by capitation </li></ul>
  38. 41. Point of Service Plans <ul><li>Choice of insurance support (e.g., indemnity, HMO, PPO) given at time service requested (and not upon enrollment for plan) </li></ul>
  39. 42. Insurance & Demand for Medical Care <ul><li>While health insurance makes medical care more accessible, true costs are hidden from patients (& providers) and thus makes medical care “too affordable” </li></ul><ul><li>Mechanisms to limit utilization: </li></ul><ul><ul><li>For patients: gatekeeper, copayments </li></ul></ul><ul><ul><li>For providers: clinical pathways/CPGs, utilization reviews, capitation </li></ul></ul>

×