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Philhealth Konsulta package coverage.pptx
- 1. Add your title BUSINESSPLAN Reporter:
- 2. OBJECTIVES: Have a basicknowledge 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 PhilhealthKonsulta? Add your words here according to your need to draw the text box size Comprehensive Outpatient Benefit Package
- 4. 1 2 4 3 Services ofhealth 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/ plateletcount 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
- 7. Drugs and Medicines T I T L E CATEGORYNAME 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
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- 9. 1 REGISTRATION Member-initiated registration • Onlineplatform 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
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- 12. First Patient Encounter Conduct primary care consultation Health screeningand assessment (diagnostic and laboratory procedures) DIspensing of medicines, if necessary Benefit Availment Process
- 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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- 16. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size 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
- 17. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size 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% ofthe 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 FirstTranche 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 SecondTranche 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 numberof 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
- 22. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size 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 tranchefor 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. Add your title 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. Add your title 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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- 25. 1 Conduct self assessment 3 Pay accreditationfee (Php 2,000.00) 2 Submission of documentary requirements (LHIO) 4 Evaluation/Approval/ Certification Accreditation Process
- 26. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw 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
- 27. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size • 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
- 28. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size • 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
- 29. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size Add your words here according to your need to draw the text box size • General Infrastructure • Signage, illuminated at night • Equipment and Supplies Technical Standards MINIMUM REQUIREMENTS FOR ACCREDITATION OF PHILHEALTH KONSULTA PROVIDERS
- 30. Add your words hereaccording to your need to draw the text box size Add your words here according to your need to draw the text box size • 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
- 31. Thank you for listening Thoughts?Questions?