THE DOCTOR IN

MANAGED CARE
ORGANIZATION

ALEJANDRO V. PINEDA JR., MD, DFM, FPAFP

RAFAEL P. BANTAYAN JR., MD, DFM, FPAFP
 The Philippine
Health Care
Delivery System
Structure of the Health Care
Delivery System

• Government Sector
• Social/Insurance
• Private Sector
 Government Sector

• DOH
• RHU
• Government Hospitals
• Tertiary Care Medical
Centers
 Social Insurance

• PhilHealth
Philippine Health Insurance
Commission

• ECC
Employees Compensation
Commission
 Private Sector

• Out of pocket (Private

Practice)
• Health Insurance
• Managed Care (HMOs)
• Employer’s Based Health
Care
Program
• Schools
 Managed Care

“An organized system of

health care delivery,
offering a comprehensive
set of benefits, in which
members are voluntarily
enrolled, and paying for a
fixed, prepaid period.”
 Types of Managed
Care
• HMO
(Health Maintenance
Organization)
• PPO
(Preferred Providers
Organization)
• IPA
(Independent Practice
Association)
• HPO
(Hospital Providers
Structural Classification of
HMO’s

1. Staff Model
2. Group Model
3. Combination
Classification of HMO’s as
Per Ownership

1. Investor–Based HMO’s
2. Community–Based
HMO’s
3. Cooperative–Based
HMO’s
HMO’s in the Philippines
(as of October 2003)

• PhilamCare
• Medicard
• Maxicare
• HMI
• SPCare
• Fortune Care
• StarCare
• Blue Cross
• Medserv
HMO’s in the Philippines
(as of October 2003)

• I.Care
• Ayala Care
• HPPI
• Pryce Care
• Caritas Health Shield
• Cocolife
• CAP Health
• IMS/Wealth Care
• MEDOCare
 Generic Structure of an
HMO

Frontline Divisions Support

Medical Services Division/Department
Marketing & Sales Administration
Finance, Treasury,
HRRD,
MS, Actuarial
Membership
Services
 Basic
Misconceptions

1. It is not a Health
Insurance.

3. It is not a Pre-Need
Insurance.
 Important Differences
Between an HMO and
Health Insurance
FEATURES HMO INSURANCE
Method of Payment Direct settlement Reimbursement
Scope of Services More Limited
comprehensive
Choice of Hospital Limited Freedom of
and Physicians choice
Membership Fee Higher Lower
Cost Effectiveness Present Not present
& Quality Assurance
Mechanisms
Supervising DOH OIC
Government
Agency
 HMO Basic Health Care
Package

I. Out-Patient Benefits
II. In-Patients Benefits
III. Emergency Care Benefits
 Benefits Package

1. Preventive Health Care

2. Out Patient Services
3. In Patient Services
4. Emergency Care
5. Optional Benefits
• Dental
• Maternity
• Prescription Medicine
• Term Insurance
• Annual P.E./ Pre-Employment
Challenges/Problems Of
Hmo’s
• Difficult relationship with
medical providers
• Lack of support/incentives
from the government
• Uncontrolled competition
• Market competition
• Lack of standards for cost
quality care
 Health Sector Reforms
Initiative Of DOH/PHIC

• Increased funding by health

insurance
• Expand coverage of PHIC to
indigent population
• Increased benefit coverage
• Reference pricing for
drugs/hospital charges
• Use of national drug formulary
• Nationwide RVS
 FUTURE DIRECTIONS

 Continued shift to manage

care by companies
 NHIC adopting managed care
features to control cost quality
 Population covered by health
insurance will increase
 HMO/Provider Partnering
 Consolidation of the Industry
 Benign Governance
TH AN K Y OU V ERY MU CH
&
GOOD D AY!