The impact of an outpatient primary care system on health care delivery in UP Diliman

Health outcomes and access to health services in the Philippines are characterized by a persistent disadvantage for the underprivileged. Underpinning these health inequities are three major problems: health workforce shortage in the public sector, administrative fragmentation and health policy fragmentation. Health facilities serving most of the population, especially the poor, remain understaffed as health professional career pathways are incentivized elsewhere. The primary care level, particularly, must depend on limited municipal or city resources, yet must integrate numerous disease-specific national health programs.

Central funding of primary care services in all localities and for all patient income groups may begin to address this situation. Paying for primary care would raise its viability as a practice option for health professionals and elevate it as a priority for local governments. Primary care systems may then recruit healthcare providers from both public and private sectors, to address the health workforce imbalance between the two. In a primary care system, each health consultation is seen by a primary care provider, who renders holistic and continuing health care and education; and refers to an established network of hospitals or specialists as necessary. This system enables efficient healthcare delivery, effective cost management, and equitable healthcare access.

UP EIDR funded pilot study of comprehensive PhilHealth primary care benefits

A primary care system funded centrally through national social health insurance with support from the UP system’s Emerging Interdisciplinary Research (EIDR) program and the Philippine Health Insurance Corporation (PhilHealth) is being piloted at the University Health Service (UHS), a government health facility at the University of the Philippines Diliman (UPD). Faculty, employees, contractual workers and their dependents – or 5,017 families – are eligible for consultations, diagnostic tests, and medications up to a certain annual amount at the UHS. An electronic medical records (EMR) system was developed by, with and for health professionals and paired with training and feedback for improvement throughout the study. Six months after the pilot program began, rural, remote, and urban primary care providers began showing interest in replicating the system using these tools and methods. The program is now in its 11th month of operations.

Patterned after the classic medical chart, an electronic medical record system was designed by, with, and for medical professionals. The system tracks health and operational data such as ICD-10 diagnoses, treatments, costs, waiting times, and more, synchronized across clinics, laboratories, the pharmacy, and records and billing. (Photo credit: Sandra Dans)

While it continues to be improved, this system has enabled secure and timely tracking of diagnoses, services, wait times, patient demographics, and utilization of the pilot health benefits. The EMR this project has developed is based on CHITS, the Community Health Information and Tracking System of the National Telehealth Center, and has been recommended for implementation at the outpatient department of the Philippine General Hospital. Surveys were also conducted to gauge patient and health worker satisfaction, pre-EMR outpatient and inpatient utilization of heath services and health benefits, and financial risk protection.

Preliminary findings demonstrate the potential value of primary care benefits and supporting elements in this model. Some of these are described in this article. Low utilization of the facility was found prior to the pilot program. The pilot benefits are increasingly being utilized in terms of consultations, diagnostics, and medications. A previously underserved population subgroup (contractual workers) has begun using primary care more equitably relative to a presumed richer subgroup of similar size (faculty), while the clinic continues to cater mostly to the presumed less affluent subgroup (non-faculty employees). The role of information dissemination appears limited in this population, suggesting that for most of the catchment population, lack of awareness was not a major contributor to low utilization. In contrast, the role of robust, useful health information systems was apparent in supporting day-to-day primary care service delivery, payment mechanisms, and monitoring and analysis.

Top and bottom: Health benefits cover all primary care services that are available at the facility and prescribed by the primary care provider – regardless of diagnosis. These include consultations and follow-ups, laboratory and imaging tests, and medications (Photo credit: Sandra Dans)

Health benefit utilization across employment subgroups

At baseline, only two percent of outpatient consultations by faculty families and only 12 percent of consults by non-faculty families utilized the UHS. The low overall utilization prompted an information campaign at the fifth to sixth month. This resulted in a sustained increase only among contractuals – from six to seven percent of all eligible consults per month prior to the campaign to 10 to 15 percent afterward. However, the uptrend in consultations in other groups appears to have begun in the 4th month. This implies little or no effect from the campaign and suggests issues deeper than awareness may be dampening utilization.

The EMR has been registering 250 to 350 new eligible patients per month (first-time visits relative to the start of the program), totaling 2,968 unique individuals by the tenth month. The peak of 413 first-time visits occurred in the first month and steadily declined, plausibly as more consultations were gradually converted from new to follow-up. In contrast, the number of eligible consultations rose from about 500 per month to about 700 per month, peaking at 910 in the 6th month (Figure 1). This suggests a gradual increase in the use of primary care after the introduction of primary care benefits. However, to distinguish this hypothesis from what could also be seasonal variation will require continued observation for a second year. As of the tenth month, there have been 6,957 eligible consultations. Dependents across all groups represented 45 percent of patients and 45 percent of consultations.

Figure 1. Overall number of monthly eligible consultations for the first ten months

The distribution of these consultations (22 percent from faculty families, 69 percent from employees’ families, and 9 percent from contractuals’ families) differs from the composition of the target population (27 percent faculty, 50 percent employees, and 23 percent contractuals). That is, relatively more employees and fewer contractuals and their dependents have been utilizing primary care benefits. Over time, however, consultations among contractuals appear to close the gap with faculty patients in the latter months (Figure 2). It should be noted that these subgroups are imperfect proxies for income level and must assume that faculty have higher salary grades. Also, contractuals may differ from non-contractuals in various parameters, whether or not income is one of those. Nonetheless, the rise in number of consultations may be worth examining more closely, comparing across groups. Significant differences in consultation trends may have policy implications as to the effect in different income groups of introducing primary care benefits.

Figure 2. Number of monthly eligible consultations by employment subgroup for the first ten months

Health benefit utilization across age groups

The majority of medications prescribed and dispensed under the program were for patients aged 41 years and older, and to a lesser extent for those aged 20-40 years. The same pattern was seen for diagnostic requests and actual laboratory and imaging services rendered, covered by the program. Over the course of the pilot program, there was a gradual rise in access to medications in terms of these metrics (Figure 3), whereas the rise in diagnostic testing was more abrupt starting at the 5th month (Figure 4). In both cases, the peak in the use of these services occurred around the 5th to 7th month.

Figure 3. Number of prescribed medications that were actually dispensed, by month of the program and by patient age bracket. Multiple medications in a single prescription are counted separately. (U5 = under 5 years old)

Figure 4. Number of requested diagnostic tests that were performed, by month of the program and by patient age bracket. (U5 = under 5 years old)

Financial risk protection

Prior to the study, outpatient healthcare costs shouldered by the target population in a three-month period averaged Php 2,148.73 per consultation, including professional fees, diagnostic tests, and medications. Within the pilot program, the average expense on primary care as of the 9th month was Php 583.95 per unique eligible person who had ever used the system, or Php 255.36 per consult derived from the following: Php 695,700.00 in consultation fees, Php 386,966.45 for diagnostics, and Php 591,808.00 for medications – or Php 1,608,774.45 in total – accrued by 2,755 unique eligible people who had conducted 6,300 consultations.

Within the pilot program, an allocation of Php 2,000 per head per year was set, to be spent on consultation fees, diagnostics and medications within the UHS. As of the 9th month only 26 patients out of 15,051 eligible beneficiaries (0.17 percent) have reached or exceeded this limit, although 79 (0.52 percent) had spent at least Php 1,950, or 97.5 percent of the spending cap.

The study also models an expansion of PhilHealth primary care benefits to all income groups. The current PhilHealth primary care benefits package (PCB1) covers the poorest Filipinos and a defined set of health services. At the UHS pilot, all PhilHealth members under the facility’s care (UP Diliman faculty, employees, and contractuals) and their dependents are entitled to free consultations, lab tests, and medications up to P2,000 annually. (Photo credit: Sandra Dans)

Next steps

Subsequent steps include follow-up surveys to determine any changes in outpatient consultation behavior and related health spending among the target population, including outside the facility, as well as effects on hospitalization rates. The EMR system will continue to be improved with graphical capabilities and national health program modules, among other plans. These will be useful as the program is replicated in study sites outside the university. In the current site, there has been positive feedback from beneficiaries as awareness and utilization grow. An extension of the program would be helpful to account for seasonal variations occurring on a yearly cycle. Also, results in the study’s eight outcome areas may still change beyond the first year of implementation.

(Article written by Jose Rafael Marfori, Antonio Miguel Dans, Mica Olivine Bastillo and Wayne Manuel)