Effectiveness of Point of Care System (POC)

TITLE

Effectiveness of Point of Care System (POC) in Decreasing Hospital Shouldered Costs for Health Care of Indigent Patients.

AUTHORS

Seurinane Sean Espanola MD (Principal Investigator), Ma. Elinore Alba-Concha MD (Co-author)

INTRODUCTION

Topic Background:

The National Health Insurance Act of 2013 Section 6 states that all citizens of the Philippines shall be covered by the National Health Insurance Program prioritizing acceleration of provision of health services to all Filipinos especially those who cannot afford such services. All indigents not enrolled in the program shall have priority provided that they shall be subsequently enrolled in the program.¹ It has been estimated that 77 million of more than 92 million Filipinos are covered by PHIC as of March 2009. And 72 percent of the 4.7 million indigent families are enrolled in the sponsored program.²

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R.A. No. 7875 targets 100 percent coverage of the indigent population³ but despite national government appropriations, sin tax collections, local government sponsorships and other sources, a vast number of poor are not yet covered by PHIC hence a mechanism of enrolling these patients at the Point of Care was established to ensure that all poor that is in dire need of quality health services is covered by Philhealth. The Point of Care (POC) system will provide indigent patients or those belonging to Class C-3 to D availment of Philhealth benefits.⁴

Ensuring access of the less privileged members of society to health care is the main aim of the POC system and the additional aim is to offset hospital shouldered costs of free services to the uninsured hence assuring sustainability. This study then focuses on the latter and looks into the initial effects of the POC system on hospital shouldered costs.

REVIEW OF RELATED LITERATURE:

Health care for all is a seemingly profound undertaking providing medical assurance for people from all walks of life however the question of sustainability and accessibility is still an ongoing issue. Despite the improving economy and work force, health care continues to remain less of a priority as finances are being concentrated to the basic needs of life.

In a study by Tsilaajav in March 2009 focusing on costing study for selected Philippine hospitals, the average unit cost of outpatient visit is P378 while emergency visit is P552. The average inpatient discharge on tertiary public hospitals would range from 1,500 to 10,000 pesos.⁵ This considerable amount is threatening to low income families compromising their general health.

There are several types of Insurance systems in the Philippines. Private health insurances works by giving coverage separately for hospitalization as well as emergency cases however premiums may be costly. Health Maintenance Organization (HMO) which is the common managed care plan in the country covers basic medical expenses from preventive and outpatient setting aside from hospitalization. And the Philippine Health Insurance Corporation (PHIC), reinventing consumer payment schemes since the establishment of Medicare, provides affordable health insurance for Filipinos at any age. Although these insurance systems may come free during employment, still there is a higher chance of discontinuity especially for those with average to low monthly incomes. And as insurance premiums may rise exponentially yearly, many of the insured in return will become uninsured.

The uninsured or people with no insurance coverage are no different from those insured. They are struck with common diseases however receiving less preventive care and screenings foregoing medical care due to costs leading to higher mortality rates.⁶ Hence the government plays a pivotal role in providing access to medical care for everyone.

The Aquino administration aims to provide accessible and available health services for all Filipinos through its Universal Health Care also referred to as Kalusugan Pangkalahatan. A health care that is accessible, efficient, equitably distributed, adequately funded, fairly finance and appropriately used by all. However despite efforts of the government to provide easy access to care especially to the poor, still there are vast majority who are uninsured hence faced with unaffordable medical bills during admissions, more out of pocket expenditures and with these thoughts in mind would later forego care because of costs and may defeat the purpose of the government of providing financial risk protection for all especially the poor.

The PHIC last November 17, 2013 with Joint order No. 2013-0033 implemented the Point of Care Enrollment Program for Hospital-Sponsored Members to further strengthen the Aquino administration program of universal health care more so focusing on the indigents as stipulated on Republic Act 7875 which clearly mentions all indigents not enrolled in the program shall have the priority in the use and the availment of the services and facilities of government hospitals. 1

The Point of Care System caters to non-member who were assessed by the Medical Social Worker as class C-3 and class D and members who are not covered due to lack of qualifying contribution and classified as class C-3 and D. Patients enrolled under the POC will be covered with in and out patient benefits including the no balance billing policy. The premium amount will be shouldered by the hospital and the coverage of Hospital Sponsored Membership shall be from the first day of confinement month and shall end on the last day of the same calendar year. Sponsorship will be continued by the National Government if the applicant remains in the same class per year upon re-evaluation.

Thru Point of Care System patients will be given enough benefits and be more confident in utilizing health care services without being burden of the costs and in return lessens the quality fee services and out of pocket expenditures and more importantly improve hospital reimbursements. However up to date this new system does not have local level analysis and there are no comprehensive studies up to date hence this study.

RESEARCH QUESTION:

The National Health Insurance Act through the National Health Insurance Program ensures health coverage for all. The point of care system covers class C-3 and D admissible or admitted patients. However to date there is still yet to be a study providing a local level analysis of the impact of Point of Care system. Additionally, it is still unknown how the system will impact the financial status of hospitals and its sustainability issues. Thus this research aims to answer the question: Will the POC implementation reduce hospital shouldered health care costs for indigent patients?

SIGNIFICANCE OF THE STUDY:

The Point of Care system has had an immediate effect on healthcare institutions and subsequently the health coverage. It aims to provide financial risk protection to all Filipinos especially the poor as implemented through the Aquino Agenda. As quality of patient healthcare is directly tied to the sustainability of hospitals, the point of care system will affect the finances and decision-making of hospitals and will directly determine whether or not financial risk protection for the poor is in fact being achieved. Hospitals will be able to identify the areas of concern and areas of growth the point of care will be providing regarding efficiency and sustainability and in return will encourage low-income patients to avail the system.

OBJECTIVES:

The general objective of this study is to compare hospital shouldered costs for patients admitted for common conditions seen in Family Medicine pre and post Point of Care.

Specifically, based on secondary data provided by the Southern Philippines Medical Center, the study shall:

1. describe patients admitted in Southern Philippines Medical Center from June 1, 2013 to March 31, 2014 in terms of a) demographic characteristics (age, sex, address) b) diagnosis c) MSW classification d) other external sources of health funds (CMAP, Lingap) e)length of hospital stay

2. compare the hospital revenue pre and post POC

3. compare hospital shouldered costs pre and post POC which includes cost of POC enrollment and additional subsidy on top of PHIC and other external sources’ reimbursement.

4. compare the hospital revenue pre and post POC.

METHODOLOGY

• Research Design
  • Retrospective Cohort
• Setting
  • Southern Philippines Medical Center, Retrospective date covering June 2013 to March 2014
• Inclusion
  • The Department of Family Medicine caters to patients aged 14-60 years old only. Hence patients who fall on the age bracket admitted with following diagnosis AGE with moderate, DHF I, CAP moderate risk or PCAP-C enrolled in the point of care system and age group and diagnosis matched patients without insurance admitted for the said conditions that were not enrolled in POC will be included.

• Exclusion
  • Charts and bills that could not be retrieved

DEFINITION OF VARIABLES

Age – refers to the chronological age of the admitted patient.

Sex – refers to the biological sex of the admitted patient.

Address – refers to admitted patients dwelling area.

Philhealth Insurance Status – refers to patients PHIC membership status.

Diagnosis – refers to patients identified cause of admission.

Total Hospital Bill – refers to the total amount incurred during length of hospital stay.

Total Out-of-Pocket Payment – refers to the amount paid by the patient not subsidized by insurance provider.

Philhealth Reimbursement – refers to the amount refunded by the Philhealth Insurance System.

Total Hospital Subsidized Costs – refers to the amount shouldered or written off by the hospital after PHIC reimbursement, reimbursements from external sources (CMAP/PDAF) and total out of pocket payments have been deducted from the total hospital bill. It would be computed as Total Bill – (PHIC Reimbursment + External Sources Reimbursement + Out of Pocket Payments.)

Data Gathering

Data gathering will commence as soon as approval from the DOH XI CERC is obtained. The principal investigator will gather the data using the charts and billing statements as the source and transcribe this in the data collection form seen in Appendix A.

Charts will be gathered and will be segregated according to diagnosis and be separated as to with or without POC. Variables will be collected as follows:

Variables

• Independent variables

1. Demographic data (age, sex, address)

2. Diagnosis

3. MSW classification

4. Other external sources of funding

5. length of hospital stay

• Main outcome measures and other dependent variables

The main outcome measure for this study is the Total Hospital Subsidy given for pre and post POC patients. Other outcome measures of interest include the total hospital bill for pre and post POC patients, the PHIC reimbursements, and the total out of pocket payments and the reimbursement from external sources. The total out of pocket payment and total hospital subsidy, if not reflected from the total bill, will be cross checked from the database of cashier section or lingap using the patients complete name or hospital number.

The co-author can randomly check the transcribed data with the original data sources to ensure data integrity.

Data Analysis

Data will be encoded in excel format and will be analyzed using Epi Info version 7.0. Descriptive statistics will be used to summarize data. Comparison of continuous variable will be made using the t test and categorical variables will be compared using the chi-square test.

Mean Total Bill – Gross Total Bill / Number of Admitted Patients under FM

Mean Amount Reimbursed by PHIC – Gross Total Reimbursement/ Number of Admitted Patients under FM

Mean Patient Out of Pocket Payments – Gross Out of Pocket Payments / Number of Admitted Patients under FM

Mean Hospital Subsidy – Gross Total Subsidy / Number of Admitted Patients under FM

Gross Total Bill – Total Bill of all Admitted patients under FM

Gross Philhealth Reimbursement – Total PHIC Reimbursement of all Admitted patients under FM.

Sample Size Calculation

Using the following assumptions:

alpha = 5 (two-sided)

power = 80

m1 = 3000

m2 = 2500

sd1 = 800

sd2 = 800

n2/n1 = 1

A total of 82 participants (41 without and 41 with POC) per disease entity will be required for this study having a sum total of 246 patients. Estimates were made using the standard 5% alpha error and 80% power since there were no previous studies for reference.

ETHICAL CONSIDERATIONS

Ethics Review

The protocol of this research will be submitted for approval to the DOH XI Cluster Ethics Review Committee.

Privacy

Patient data will be anonymized prior to analysis. No personal contact with individual patients shall be made.

Confidentiality

Patient data for analysis will be anonymized.

How will you keep the data and for how long?

After initial analysis, the anonymized data will be stored electronically and will be retained for 5 years from the time of initial analysis under the custody of Dr. Seurinane Sean Espanola and Ma. Elinore Concha. Within this retention period, the investigators listed in this protocol may refer any number of times to the data for clarification, further analysis and/or re-analysis.

How will you discard/dispose of the data?

After the 5-year retention period, the electronic data will be permanently deleted.

Who can access data?

Only the investigators listed in this protocol will be given access to the raw data for reference and initial or subsequent analysis.

Extent of use of study data

Data shall be used solely for the objective of analysis of the Point of Care System, as stated in previous sections of this protocol proposal. No facts or information shall be released without the prior consent of the medical director of the hospital. Necessary steps shall be taken to assure that this information will not be made accessible to persons outside of the research team.

Authorship and contributorship

a. Who are the authors or contributors to the present paper?

The authors and contributors to this study shall be given proper recognition in the formulation of the follow-up paper. Authors and Co-authors include Dr. Seurinane Sean Espanola and Dr. Ma. Elinore Concha respectively

b. Acknowledgment of original data collectors

Proper acknowledgment shall be given to the Southern Philippines Medical Center for original data collection.

c. Written consent of original data collectors that the data can be used for further research

Written consent for use of secondary data shall be requested from Dr. Leopoldo J. Vega, the Chief-Of-Hospital.

Conflicts of interest

The author and co-author hereby declare that they have no conflicts of interest.

Publication

Publication shall be pursued at the onset of writing of the paper for this study. Submissions shall be sent to relevant publishers who can help promote the awareness of this topic.

Funding

Dr. Seurinane Sean Espanola is presently seeking funds to cover the expenses for this research.

Dummy Tables

DUMMY RESULTS Table 1. Comparison of Baseline Characteristics

*using t-test

**using chi-square test

Table 2. Comparative parameters between POC and pre-POC PhilHealth – sample (Note: separate tables will be made for the other medical case rate diagnoses)

BUDGET

Administrative expenses and supplies

For office supplies and support expenses as requested by the Health Sciences Program. Funds would go towards providing computer and office space and travel if needed.

TIMETABLE

References

1. Philhealth. November 7, 2013 Manual of Operations and Procedures for the Implementation of the Point of Care Enrollment Program for Hospital-Sponsored Members. (Philhealth Joint Order 2013-0033) PHIC, Pasig.

2. Philhealth at a Glance. The National Health Insurance Program. Senate Economic Planning Office. November 2009.

3. Philhealth. October 14 2013. Implementation of the Point of Care Enrollment Program (Philhealth Circular 0032-2013). PHIC. Pasig

4. Philhealth. March 26, 2013. Enrollment of the Critical Poor under the Sponsored Program of the National Health Insurance Program at Point of Service. (DOH Department Order/Philhealth Office Order2013-0031). PHIC, Pasig.

6. The Kaiser Commission on Medicaid and the Uninsured. September 2013. Key Facts about the Uninsured Population.

APPENDIX A

POC Study Data Collection form

Patient’s Initials: ______________________________________________

Hospital Record number: _________________________________________

Age: ______Sex: __Male __Female

Diagnosis: ______________________________________________________

MSW Classification: __C3__D

Date Admitted: ________________Date Discharged: ______________

Detailed Hospital Bill (attach if possible)

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