Medical History Managemen t Medical Economic s Bioethi cs Medical Jurispruden ce Right s Medical Anthropology
1.health financing 101 Dr. Caballes
Nov 20, 2014
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: [email protected], [email protected]
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
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: [email protected], [email protected]
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
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Transcript
Medical
History
Management
Medical Economics
Bioethics
Medical Jurisprudence
Rights
Medical Anthropology
Risks of Surgical Conditions: Occurrenceand
Cost
Introducing Medical Students to Health Financing
Risks of Surgical Conditions: Occurrence and Cost
Average Family Hospitalization Expenses***
P 5,874
Poverty Threshold**** P 4,835
Percentage of Families Below Threshold****
27.5 %*** FIES, 2000 **** NSCB, 2000
NDHS, 2008
Concepts & ContextsALVIN B. CABALLES, MD
Salient Points
•Sourcing
•Strategies
•Scenarios
•Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 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)
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
More on “Catastrophic Health Expenditures”
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
More on “Catastrophic Health Expenditures”
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
More on “Catastrophic Health Expenditures”
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Pooling Risks: Health & Financial
SourcingStrategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Pooling Options
Characteristics
raised from general taxes/duties; may be done at different government levels (e.g., local taxes)
requires administrative capacity
may be vertically redistributive (e.g., subsidized health expenses for the poor)
Advantages •potential to generate most resources
Disadvantages
• sensitive to economic downturns
•horizontal equity often difficult (e.g., which sector assumes more tax burden vs. benefits)
• taxes diminish wages/production
•undermined by bad governance and widespread tax evasion
GOVERNMENT REVENUES
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Pooling Options
Characteristics
insurance purchased voluntarily
premium payments adjusted for risks
Advantages •no “free-riders”
•free choice (of plan)
Disadvantages
•more limited risk pooling
•risk selection/cream skimming
•often regressive premium rates
•substantial transaction costs
•limited regulation
PRIVATE INSURANCE
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Pooling Options
Characteristics
compulsory enrollment (for specified population)
social compact (defined premiums and guaranteed benefits, not “welfare”)
“earmarked tax” (publicly administered fund designated for health goods and services)
Advantages
•discrete fund purposely for health activities
•greater public willingness to participate
Disadvantages
•similar to general revenue, but of less magnitude
SOCIAL HEALTH INSURANCE
Sourcing
Strategies
Scenarios
Synergiess
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Once Again…
Sourcing
Strategies
Scenarios
Synergies
Private/Indemnity
SHI
PremiumsReflects 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
Pooling Options
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Sourcing
Strategies
Scenarios
Synergies
Insurance Concerns
Information Assymetry
Moral Hazard
Adverse Selection
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Sourcing
Strategies
Scenarios
Synergies
Insurance Concerns
While health insurance makes medical care more accessible, true costs are hidden from patients (& providers) and thus makes medical care “too affordable”
Mechanisms to limit utilization:For patients: gatekeeper,
copayments
For providers: clinical pathways/CPGs, utilization reviews, capitation
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Philippine Trends: Total
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Philippine Trends: Main Sources
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Philippine Trends: Health Insurance
Sourcing
Strategies
Scenarios
Synergies
NDHS, 2008
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Philippine Trends: PHIC
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Demographic Transition: Double Burden
Sourcing
Strategies
Scenarios
Synergies
Preston, 1975
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Sourcing
Strategies
Scenarios
Synergies
Demographic Transition: Financing Effects
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Sourcing
Strategies
Scenarios
Synergies
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 April 2010
Sourcing
Strategies
Scenarios
Synergies
Economic Growth & Health Financing Sustainability
ALVIN B. CABALLES, MDHEALTH FINANCING SUMMIT
UP Diliman14 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
Thank you for being a captive-ating audience
Managed Care in RPManaged Care in RP
1st Asian country
started in late 1970’s
reached peak of 38 HMO’s in late 1990’s
surpassed indemnity insurance in revenues
2002: 29 operating HMO’s; 15 AHMOPI members (95% of market)
Indemnity Health InsuranceIndemnity Health Insurance
“casualty insurance” Reimbursement for certain expenses or
for loss of income Consumer choice not very restricted Encourages over-utilization of medical
care and increased expenses “traditional” indemnity insurance losing
market dominance
“casualty insurance” Reimbursement for certain expenses or
for loss of income Consumer choice not very restricted Encourages over-utilization of medical
care and increased expenses “traditional” indemnity insurance losing
market dominance
Managed Care PlansManaged Care Plans
MCP firm involved in both financing & actual
utilization of health service acts as patient’s “agent”, to get better care
at lower prices has to earn (even if non-profit), therefore
has all the incentive to provide quality care at least cost
MCP firm involved in both financing & actual
utilization of health service acts as patient’s “agent”, to get better care
at lower prices has to earn (even if non-profit), therefore
has all the incentive to provide quality care at least cost
Types of MCP FirmsTypes of MCP Firms
Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service Plans (POS)
Administrative Service Only (ASO)
Minimum Premium Plans (MPP)
Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service Plans (POS)
Administrative Service Only (ASO)
Minimum Premium Plans (MPP)
Health Management Organization
Health Management Organization
Has network of accredited providers
“Gatekeeper” for care/referrals
Adheres to Clinical Practice Guidelines
Only care given within network paid
Closed-panel: firms where all care is in-house
Has network of accredited providers
“Gatekeeper” for care/referrals
Adheres to Clinical Practice Guidelines
Only care given within network paid
Closed-panel: firms where all care is in-house
Preferred Provider OrganizationPreferred Provider Organization
“middleman” between purchaser and
provider, more manager than
financier
also adheres to utilization controls
providers paid on discounted rates or
by capitation
“middleman” between purchaser and
provider, more manager than
financier
also adheres to utilization controls
providers paid on discounted rates or
by capitation
Point of Service PlansPoint of Service Plans
Choice of insurance support (e.g., indemnity, HMO, PPO) given at time service requested (and not upon enrollment for plan)
Choice of insurance support (e.g., indemnity, HMO, PPO) given at time service requested (and not upon enrollment for plan)
Insurance & Demand for Medical Care
Insurance & Demand for Medical Care
While health insurance makes medical care more accessible, true costs are hidden from patients (& providers) and thus makes medical care “too affordable”
Mechanisms to limit utilization: For patients: gatekeeper, copayments
For providers: clinical pathways/CPGs, utilization reviews, capitation
While health insurance makes medical care more accessible, true costs are hidden from patients (& providers) and thus makes medical care “too affordable”
Mechanisms to limit utilization: For patients: gatekeeper, copayments
For providers: clinical pathways/CPGs, utilization reviews, capitation
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