Philippine Primary Care Studies

Pilot study at the UP Health Service

Comprehensive primary care systems financed by social health insurance in
representative areas in the Philippines

Stakeholders’ Forum on Primary Care Training Objectives

NAST | PPCS

Hotel Jen Manila, Pasay City

01 February 2018
 Outline

1. Rationale & framework

2. Methods & key features

3. Initial Results
 What is Primary Care?
Primary Care is a system where patients access healthcare,
with 4 main functions:
Primary Care System

Patient
1. FIRST CONTACT

2. COMPREHENSIVE
Primary Care 4. PRINCIPAL POINT OF
CARE
Provider CONTINUING CARE

Laboratories Pharmacies Specialists Facilities

3. COORDINATOR FOR SERVICE NETWORK

Source: used with permission from Ho BL (2017). Advancing primary care for all Filipinos. [presentation] presented at the Benefit
Committee Meeting of the Philippine Health Insurance Corporation, July 2017.

Primary Health Care vs Primary

Care
Population and Individual Based Services

Primary Health Public Health Personal Care

Care

Population Based Individual Based

Primary
Care
Secondary Care
Primary Care
Tertiary Care

ADVANCING PRIMARY CARE FOR ALL FILIPINOS

Inequities in Access
Too Little Health Care Too Much Health Care

Mr. Jose Mrs. Rosete

42 years old 56 years old
From Busuanga From Quezon City

- High Blood - Diarrhea (gastro)

- Diabetes - Dizziness (neuro)
- Tuberculosis - Diabetes (endo)
- Kidney ds (nephro)
No consultation - Gout (rheuma)
No medications - ECG ischemia (cardio)
INEQUITIES IN ACCESS AND OUTCOMES
FROM WOMB TO TOMB
Inequity in Inequity in
Healthcare Access Health Outcomes
Pregnancy Unattended births Neonatal mortality
- poorest quintile (58%) - poorest quintile (19/1000)
1 1
- richest quintile (4%) - richest quintile (9/1000)
Childhood Complete vaccination Under-5 mortality
- NCR (80%) - poorest quintile (5.2/1000)
- ARMM (30%) 1 - richest quintile (1.7/1000)1
Adult Life Current Tobacco use Heart attack rates
- poorest quintile (33%) - lowest quintile 40% higher
- richest quintile (18%) 2 than richest 3

1 2 3
NDHS, 2013; National Nutrition Survey, 2013; Interheart Study, 2007
Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

WORKFORCE SHORTAGE & MALDISTRIBUTION

ADMIN. FRAGMENTATION
POLICY FRAGMENTATION

INEQUITY IN ACCESS
TO CARE
Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

HEALTH SYSTEM

HEALTH OF POOR HEALTH OF RICH

 Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

POORER RICHER
AREAS AREAS

HEALTH OF POOR HEALTH OF RICH

Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

WORKFORCE SHORTAGE & MALDISTRIBUTION

ADMIN. FRAGMENTATION
POLICY FRAGMENTATION

INEQUITY IN ACCESS
TO CARE
Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

HEALTH OF POOR HEALTH OF RICH

Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE
DIFFERENT
LGUs, LEVELS

HEALTH OF POOR HEALTH OF RICH

Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

WORKFORCE SHORTAGE & MALDISTRIBUTION

ADMIN. FRAGMENTATION
POLICY FRAGMENTATION

INEQUITY IN ACCESS
TO CARE
Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

HEALTH OF POOR HEALTH OF RICH

Healthcare System Analysis
TRIPLE BURDEN OF
DISEASE

? ? ? ? ? ?
HEALTH OF POOR HEALTH OF RICH
 Outline

1. Rationale & framework

2. Methods & key features

3. Initial Results

4. Future Plans and Implications

Envisioned Primary Care-
Oriented Healthcare System
TRIPLE BURDEN OF
DISEASE

POPULATION
 Envisioned Primary Care-
Oriented Healthcare System
TRIPLE BURDEN OF
DISEASE
o ₱
1 ₱
₱ ₱ ₱ ₱ ₱
₱ ₱ ₱₱ ₱ ₱ ₱ ₱₱ ₱
o ₱₱ ₱₱ ₱ ₱ ₱ ₱
2
o
3 comprehensive PCB
- pay per service,
NOT disease packaged

- rich and poor

NOT lowest quintile only

POPULATION
Unique features
₱ ₱ ₱
₱ ₱
₱ ₱ ₱
₱ ₱ ₱
₱
₱₱ ₱
PATIENTS

A. B.
Paying for disease packages Paying for services
 Unique features
• Runs on the principle of risk sharing

Budget Coverage

sick
consultation

P600 P600 P600 P1800

 Envisioned Primary Care-
Oriented Healthcare System

comprehensive PCB sustained x 1yr EMR

- pay per service, - 1st contact = register, profile - coordinated care
- rich and poor - follow ups = continuing care - regulation
- training - monitoring
- training
 Triage Nurse
or Midwife
DOH, PhilHealth
EMR
LGU
Records

EMR

Doctor DATA
Lab Rx Med Rx
BILL
Cash/Billing

Pharmacy
receipt EMR receipt EMR

Laboratory EMR

Radiology EMR
Unique features of the Study
• Runs on the principle of risk sharing
• Registration is on consultation
• Efficient check-ups/risk assessment
– Timing is opportunistic
– Tests are targeted
• Universal in scope
– No priority disease
– No priority test
– No priority medicine
• Universal in coverage (rich & poor)
 Triage Nurse
or Midwife
DOH, PhilHealth
EMR
LGU
Records
REACH OUT RECRUIT REGULATE
RETAIN EMR REASSESS

Doctor DATA
Lab Rx Med Rx
BILL
Cash/Billing
RETRAIN
Pharmacy
receipt EMR receipt EMR

Laboratory EMR

Radiology EMR
In terms of training
TRAINING BHW
MIDWIFE
TRAINING NURSE
DOCTOR

TRAINING

TRAINING

TRAINING

TRAINING
In terms of training

NURSE
BHW ROLE
- Skill / Knowledge #1
BHW - Skill / Knowledge #2 …

NURSE ROLE
- Skill / Knowledge #1
- Skill / Knowledge #2 …
In terms of training

MIDWIFE

BHW
NURSE
DOCTOR

PRIMARY CARE TEAM

 STRATEGY OBJECTIVES

RECRUIT Motivational workshops (New hires)

Fees for services HCW satisfaction

RETRAIN Lectures Quality of Care

Workshops HCW Knowledge

RETAIN Motivational Workshops (Quit rates)

Fees for services HCW satisfaction

REGULATE Require use of EMR, ICD % Compliance

and Formulary meds

REASSESS Survey Instruments Hospitalization

OOP payments
Utilization
Costing
REACH OUT Brochures, ads, videos Patient satisfaction
Meetings w people/leaders
 Outline

1. Rationale & framework

2. Methods & key features

3. Initial Results
HEALTHCARE WORKER SATISFACTION (n=33)

Compensation 50.0%  67.7%

Working Conditions 76.4%  70.3%

Job contentment and

morale 82.3%  85.4%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Proportion Assigning scores of 4+

 HCW KNOWLEDGE (n=11)
Rank

Pre Post

1. Adolescent 1. CV risk – ISH protocol

2. TB 2. Adolescent
3. Cervical cancer screening 3. NCD
4. NCD 4. Smoking cessation
5. Asthma 5. TB
6. Immunization 6. Asthma
7. CV risk – ISH protocol 7. Immunization
8. Smoking cessation 8. Cervical cancer screening
9. Breast cancer screening 9. Breast cancer screening
10. Pedia 10. Pedia
 QUALITY OF CARE (N=3207)
Study End
Indicator Potential Concern Result
ADULTS
Hypertension control rate effectiveness 59.1%
Thiazide use for HTN underuse/overuse 3.6%
Metformin use for diabetes underuse 22.8%
Diabetes blood sugar monitoring underuse 84.1%
Diabetes control rate effectiveness 76.1%
Recorded smoking history underuse 1.6%
PEDIATRIC
Antibiotic use for URTI overuse 37.6%
Mucolytics for URTI overuse 2.7%
Montelukast for asthma overuse 7.6%
Vitamin use overuse 2.1%
Zinc use for diarrhea underuse 0%
Smoking history taken (ages 10 to <18 years) underuse 0%
MIXED (ADOLESCENT AND ADULT)
Smoking history taken (ages 10 years and older) underuse 1.4%
UTILIZATION (%)
= # who use facility = 8.9 %  52%
# who need healthcare

OUT OF POCKET EXPENSES (%)

= OOP expenses
total expenses = 100%  86%

HOSPITALIZATION (%)
= # hospitalized = 15%  26%
total population
 COSTING AND PRICE

Utilization - Cumulative number of beneficiaries

Cumulative price per service

* Average “price” per patient = P698.74

* Average “ cost” per patient = P730.97
 Outline

1. Objectives and Strategies

2. Initial Results

3. Future Plans and Implications

 Potential National Issues
1. EMR use and development
 software, hardware, and 5. Workforce / work-hours and
regulatory solutions utilization
2. ICD and Formulary use
6. Fraud control
 software and regulatory • Eligibility List
solutions
• Single EMR concept
3. Primary Care Training • Bar code, RFID or Biometrics
 In-practice (doctors, nurses, • patient vouchers
midwives, BHWs) • Random SMS verification
 Curricular
ONGOING STUDIES

1. Corporate setting (UP Diliman)

population = 15,051 P9,000,000
2. Rural setting (Samal, Bataan)
population = 35,652 P21,000,000
3. GIDA setting (Bulusan, Sorsogon)
population = 22,000 P13,000,000
4. Urban setting (FamilyDoc, Cavite)
REQUEST

1. Corporate setting (UP Diliman)

population = 15,051
2. Rural setting (Samal, Bataan)
population = 35,652 P19,000,000
3. GIDA setting (Bulusan, Sorsogon)
population = 22,000 P11,000,000
4. Urban setting (FamilyDoc, Cavite)
THANK YOU!
Extra Slides
 Outline

1. Healthcare System Analysis

2. What is Primary Care

3. A Roadmap to Primary Care

Physicians/10,000 population

Philippines 2014 (2.5)

HHRDB
 Outline

1. Healthcare System Analysis

2. What is Primary Care

3. A Roadmap to Primary Care

 A Structural Definition

1° CARE

2° CARE

3° CARE
 A Practical Definition
Primary Care is “outpatient” care funded by Social Health
Insurance (eg – PhilHealth).

Why do we need it?

1. There are more outpatient facilities than hospitals;
2. Most diseases need outpatient care, NOT hospitalization;
3. Patients need outpatient care before hospitalization;
4. Prevention needs outpatient NOT hospitalization.
Healthcare System Analysis
DOUBLE BURDEN OF
DISEASE

WORKFORCE SHORTAGE Healthcare

POLICY FRAGMENTATION Primary
System
Care
Reform!
ADMIN. FRAGMENTATION

INEQUITY IN ACCESS
TO CARE

INEQUITY IN HEALTH
OUTCOMES
 Outline

1. Healthcare System Analysis

2. What is Primary Care

3. A Roadmap to Primary Care

A ROADMAP TO PRIMARY CARE
(UPDATES)

The importance of primary

care needs to be recognized:
RECRUIT - by the government
- by practitioners
RETRAIN - By the people

REGULATE
REASSESS
A ROADMAP TO PRIMARY CARE

RECRUIT Short Course Curriculum:

- Infectious Diseases
RETRAIN - Maternal/Child Health
- Non-communicable Disease
- Health System Navigation

REGULATE
REASSESS
A ROADMAP TO PRIMARY CARE

Why healthcare workers stay1

RECRUIT - To serve the country
- To be with their family
RETRAIN Why healthcare workers leave2
- Unemployment
- Underemployment
- Misemployment
- Unjust working conditions
REGULATE
REASSESS Ebesate 2012; Lorenzo 2005
1 2
A ROADMAP TO PRIMARY CARE

RECRUIT
RETRAIN
EMR use
International Classific.of Disease
REGULATE Use of Formulary
REASSESS Compliance with Guidelines
A ROADMAP TO PRIMARY CARE

RECRUIT
RETRAIN 1. Caregiver knowledge
2. Quality of Care
3. Health outcomes
4. Utilization!!
5. Out-of-pocket expenses
REGULATE 6. Patient satisfaction

REASSESS 7. Caregiver satisfaction

8. Administrative efficiency
 Health Care Expenditures and
Mortality 5 Year Followup:
United States, 1987-92
(age 25 and older)

• if personal doctor is primary care

rather than specialist
– 33% lower cost of care
– 19% less likely to die*

*(after controlling for age, gender,

income, insurance, smoking, perceived
health (SF-36) and 11 major health
conditions)
Adapted from Starfield (2004). Primary Care, Health, and Equity [presentation].
Supercourse lecture. http://www.pitt.edu/~super7/17011-18001/17361.ppt
 Primary Care Score vs. Health Care
Expenditures, 1997
2 UK
DK
Primary Care Score

NTH
1.5 FIN
SP
CAN
AUS
1
SWE
JAP

0.5 GER US
BEL FR

0
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures
Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.
Adapted from Starfield (2004). Primary Care, Health, and Equity [presentation].
Supercourse lecture. http://www.pitt.edu/~super7/17011-18001/17361.ppt
 Primary Care and Life Expectancy
(US states)
78 .
. CT..WAMN
HI

. . ND .MA
77 .NE SD. . CA
.
ID
.ME .NH . OR
Life Expectancy

76 . . ID . AZ RI .
.IA UT . . NM . MT .NJ
.TN . .NY
75 . .TX . .AR WI. KS . PA
FL

74 . .WV DE
MI
. NC KY .VA .
.MS AL . IL MD

73 .NV .AK
. GA
. SC
72 . LA R=.54
P<.05

71
4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50
Primary Care Physicians/10,000 Population
Adapted from Starfield (2004). Primary Care, Health, and Equity [presentation].
Supercourse lecture. http://www.pitt.edu/~super7/17011-18001/17361.ppt
 Training Programs in Primary Care
Community Health Primary Primary Care PC Provider
Worker Care Certificate (Level 0)
Workshop

Graduate Primary Primary Care PC Provider

Midwifery Care Certificate (Level 1)
Workshop

Graduate Primary Primary Care PC Provider

Nursing Care Certificate (Level 2)
Workshop

Graduate Primary Primary Care PC Provider

Physician Care Certificate (Level 3)
Workshop
Master’s Degree?

Family and Primary Primary PC Provider

Comm. Med Care IM Care Ped. (Level 4)