2. OBJECTIVES:
Have a basic knowledge on Philhealth Konsulta
packge
1
Discuss whether or not to apply for Philhealth
Konsulta Accreditation
2
At the end of this lecture, audience mst be able to:
3. What is Philhealth Konsulta?
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Comprehensive Outpatient Benefit
Package
4. 1 2
4
3
Services of health care
professionals
Provision of preventive
health services
Diagnostic and laboratory
services
Prescription and dispensing
of drugs
Benefits include:
Consultation and case management for
any conditions, including individual
health education
5. CBC w/ platelet count
Urinalysis
Fecalysis
Sputum Microscopy
Fecal Occult Blood
Pap smear
Lipid profile (Total Cholesterol, HDL
and LDL Cholesterol, Triglycerides)
Laboratory/Diagnostic Examinations
T
I
T
L
E
FBS
OGTT
ECG
Chest X-Ray
Creatinine
HbA1c
6.
7. Drugs and Medicines
T
I
T
L
E
CATEGORY NAME CATEGORY NAME
Antimicrobial • Amoxicillin
• Co-Amoxiclav
• Nitrofurantoin
• Ciprofloxacin
• Cotrimoxazole
• Clarithromycin
Anti-diabetic • Metformin
• Gliclazide
Fluids and
Electrolytes
• Oral Rehydration Salts Anti-
dyslipidemia
• Simvastatin
Anti-Asthma • Prednisone
• Salbutamol
• Ftuticasone+Salmeterol
Anti-
hypertensives
• Enalapril
• Metoprolol
• Amlodipine
• Hydrochlorothiazide
• Losartan
Antipyretics • Paracetamol Anti-
thrombotics
• Aspirin
Anti-histamine • Chlorpheniramine Maleate
9. 1
REGISTRATION
Member-initiated registration
• Online platform
Third-party assisted registration
• Local Government Units (LGU)
• Private and government Health
Facilities (HF)
• Employers
• Educational Institutions
Philhealth-assisted
• Local Health Insurance
Offices (LHIOs)
• -PCARES
10. • Sinait
• Cabugao
• San Juan
• Badoc
• Pinili
• Nueva Era
Target population:
• Employees
• Inpatients
• Outpatients
• Teachers
• *and their
dependents
13. Benefit Availment Process - First Patient Encounter (FPE)
• Philhealth Identification Number (PIN)
• Name
• Date of Birth
• Sex
• Client type (Member/Dependent)
• Past Medical History
• Family History
• Personal and Social History
• Vital signs, anthropometrics
The following information should be
captured during the FPE:
The FPE can be conducted by any primary
care worker
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Payment mechanism where insurer pays an
amount for a specific population, over a
specific period of time, regardless of whether
or not they use all identified health services
What is capitation?
Payment
The benefit shall be paid as an annual
capitation computed and released as a
performance-base payment
The maximum per capita amount for
Konsulta shall be at Php 500.00 at goverment
facilities
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Payment
Capitation paid to
provider
With capitation, an amount is
allocated for and paid to
providers to cover for the
entire catchment population
Members in the catchment
population can access to
identified benefits based on
need even if it cost more than
their paid capitation.
This is risk pooling.
500
500
500
500
300
700
1000
18. Capitation Tranches
40% of the Capitation
PHP 200.00
(max)
Based on Fixed Costs
Computed based on number of members registered with first
patient encounter X PHP 200.00
60% of the Capitation
php 300.00
(max)
Based on Performance
Computed based on the number of registered members with
first patient encounter as of December that year and achieved
performance targets at the end of the year.
PHP 500.00/
capita
19. Computation of First Tranche
Month Number of individuals
registered per month
Number of registered
beneficiaries with FPE per month
Calculation Sample Capitation
January 2000 1500 1500 * 200.00 300,000.00
February 2000 2000 2000 * 200.00 400,000.00
March 1500 500 500 * 200.00 100,000.00
April 3500 3000 3000 * 200.00 600,000.00
May 2000 600 600 * 200.00 120,000.00
June 1000 1500 1500 * 200.00 300,000.00
July 500 1000 1000 * 200.00 200,000.00
August 1500 750 750 * 200.00 150,000.00
September 2500 1300 1300 * 200.00 260,000.00
October 1000 800 800 * 200.00 160,000.00
November 1500 1000 1000 * 200.00 200,000.00
December 1000 900 900 * 200.00 180.000.00
Total 20,000 14,850 14850 * 200.00 2,970,000.00
20. Computation of Second Tranche
Performance Indicators
Percentage of beneficiaries who availed
Konsulta services over beneficiaries with FPE
Target Weights
1 Primary Care Consultation
Unique registered beneficiaries who consulted
a primary care doctor
Number of unique individuals who consulted
at least once / Total number of registered
beneficiaries with validated FPE
100% 30%
2 Utilization of Laboratory
Unique laboratory services done
Number of unique individuals who recieved
laboratory service / Total number of registered
beneficiaries with validated FPE
50% 30%
3 Dispensing of Medicines
Unique registered beneficiaries who recieved
antibiotics as prescribed by their primary care
doctor
Number of unique individuals who recieved
indicated medicines for communicable
diseases / Total number of registered
beneficiaries with validated FPE
15% 10%
4 Dispensing of Medicines
Unique registered beneficiaries who recieved
NCD medications by their primary care doctor
Number of unique individuals who recieved
indicated medicines for non-communicable
diseases / Total number of registered
beneficiaries with validated FPE
20% 30%
Sum of all indicators x Weights 100%
Performance indicators in computing for the Performance Factor
21. Performance Indicators
Total number of registered
beneficiaries with validated
FPE = 14,850
Percentage of beneficiaries who availed
Konsulta services over beneficiaries with FPE
(a)
Performance
count
(b)
Performance
percentage
(a=b/14,850)
Target
(c)
Weights
(d)
Performance
factor
(e=a/cxd)
1 Primary Care Consultation
Unique registered
beneficiaries who consulted
a primary care doctor
Number of unique individuals who consulted
at least once / Total number of registered
beneficiaries with validated FPE
8,000 54% 100% 30% 16%
2 Utilization of Laboratory
Unique laboratory services
done
Number of unique individuals who recieved
laboratory service / Total number of registered
beneficiaries with validated FPE
3,000 20.% 50% 30% 12%
3 Dispensing of Medicines
Unique registered
beneficiaries who recieved
antibiotics as prescribed by
their primary care doctor
Number of unique individuals who recieved
indicated medicines for communicable
diseases / Total number of registered
beneficiaries with validated FPE
2,000 13.5% 15% 10% 9%
4 Dispensing of Medicines
Unique registered
beneficiaries who recieved
NCD medications by their
primary care doctor
Number of unique individuals who recieved
indicated medicines for non-communicable
diseases / Total number of registered
beneficiaries with validated FPE
1,500 10.1% 20% 30% 15%
Sum of all indicators x Weights 100% 52%
Performance indicators in computing for the Performance Factor
Computation of Second Tranche
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Second Tranche = Number of registered beneficiaries with first patient
encounter X Performance Factor X (Capitation Amount X 60%)
= 14,850 X 52% X (Php300.00)
= Php 2,316,600.00
(Maximum: Php 4,455,000.00)
Computation of Second Tranche
23. The first tranche for the succeeding years
of retained beneficiaries will be paid in full
without need for another FPE, provided
that the KPP conducted at least one
medical consultation for the beneficiary
within the previous year.
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If the KPP did not conduct at least one
medical consultation within the previous
year, a new FPE must be performed in the
succeeding year to avail of the first tranche
of capitation payment.
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Capitation Tranches
Year 1 Year 2 Year 3 Year 4
• FPE done
• Medical
Consultation
done
• No need for FPE
• Medical
Consultation
• No need for FPE
• Medical
Consultation
• No need for FPE
• Medical
Consultation
FIrst Tranche
payment
Automatic first
Tranche payment
Automatic first
Tranche payment
Automatic first
Tranche payment
Year 1 Year 2 Year 3 Year 4
• FPE done
• Medical
Consultation
done
• No Medical
Consultation
done
• No Medical
Consultation
done
• FPE
• Medical
Consultation
FIrst Tranche
payment
Automatic first
Tranche payment
No first Tranche
payment
First Tranche
payment
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Add your words
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the text box size • Ability to conduct preventive/screening
services and health education
Service Capability
MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA
PROVIDERS
• Capable of providing services for required
laboratory and radiologic services
• Capability to dispense required medicines
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• Full-time or full-time equivalent Physician
(1:20,000 beneficiaries) – PhilHealth
accredited
• Two (2) support staff - a nurse and another
allied medical staff, either a nurse or a
midwife.
HUMAN RESOURCE
MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA
PROVIDERS
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• Installation of PhilHealth-certified Electronic Medical Record (EMR)
• Complete and functional computer set-up with the following
specifications:
• OS Supported: Win7 x64, Win7 x32, Win10 x32, Win10 x64,
Windows 10
• Memory: Minimum 64MB RAM
• Storage Capacity: Minimum 500GB
• printer
• face capturing device (e.g. webcam/mobile phones)
• Back-up for interruptions in power supply such as generator or offline
compatible solution
• Individual health profiles in EMR or equivalent
Functional Health Information System
MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA
PROVIDERS
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• General Infrastructure
• Signage, illuminated at night
• Equipment and Supplies
Technical Standards
MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA
PROVIDERS
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• Updated Mayor/business permit/PTR of Primary Care Physician or Department of Health
(DOH) License of the PhilHealth Konsulta provider
• Updated DOH license of laboratory services
• Updated DOH license of radiologic services (Level 1 Xray service)
• Updated DOH license of pharmacy services
• Signed performance commitments of the PhilHealth Konsulta Provider and Primary Care
Workers - signed by 2 authorized representatives
• Provider Data Record
• Training certificate on Direct Sputum Smear Microscopy (DSSM)
• Nin-Disclosure Agreement
• Self-assessment Tool
• Schedule of duties
• Emergency preparedness plans (exit, evacuation plans)
• Adequate and appropriate information materials (e.g. flyers, brochures, posters, audio
visual presentation) on health and wellness such as anti-smoking, and promotion of
proper diet, exercise, immunization, and proper infection controls.
Documentary Requirements
MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA
PROVIDERS
