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Commission on Audit

Republic of the Philippines

SAI and Encouraging Attainment

of SDGs

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

8^th ASOSAI Symposium

September 8, 2021

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Approaches to SDGs

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• Commission on Audit
• Republic of the Philippines

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PERFORMANCE AUDIT OF PROGRAMMES CONTRIBUTING TO SDGs

A. Completed Audits

• National Health Insurance Program
• National Greening Program
• Dairy Program
• Bureau of Fire Protection Modernization Program

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B. Ongoing Audits

• Cooperative Audit of SDG Implementation: Strong and Resilient National Public Health System (linked to SDG 3.D)
• National Solid Waste Management Program

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Approaches to Audit SDGs

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• Commission on Audit

Republic of the Philippines

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SDGs related AUDIT IMPLEMENTATION

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Performance Audit of National Health Insurance Program (NHIP)

Quick Facts on the NHIP:

• Created under the National Health Insurance Act of 2013

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• Provides health insurance coverage and ensure affordable, acceptable, available and accessible health care services access to citizens

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• Implemented by the Philippine Health Insurance Corporation (PhilHealth) using the All Case Rate (ACR) as the provider payment mechanism

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• PhilHealth shifted from Fee-for-Service (FFS) to case rate payment scheme to simplify reimbursement rates and improve turn-around-time (TAT) of processing of claims from the health care institutions (HCIs)

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Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

List of covered Illnesses and the corresponding fixed coverage.

Philhealth

Benefit Schedule -

Performance Audit Office

All Case Rate Payment Scheme

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Patient visits accredited Hospitals for treatment.

Philhealth-accredited doctor identifies the illness and treats the patient.

Hospital computes the bill. If the illness is covered, the Case Rate is deducted from the bill.

Patient is discharged from the hospital.

Patient pays the bill. If the Case Rate is greater than the actual cost, then its free. If not, then there will be an out of pocket expense.

Performance Audit Office

How ACR Works?

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Hospital files its claims to Philhealth for reimbursement

Philhealth verifies the claim then pays the Hospital.

If the Case Rate is greater than the actual costs then the Hospital gets to keep the difference as its efficiency gain

If the Case Rate is lesser than the actual costs then the Hospital incurs an efficiency loss

Efficiency Gain

Efficiency Loss

Performance Audit Office

Efficiency Gain vs. Efficiency Loss

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

• If the Case Rate is less than the actual hospitalization costs and the patient is not entitled to No Balance Billing Policy

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• If illness or medical intervention for the patient is not included in the list of ACR

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Performance Audit Office

Out of Pocket (OOP) Expenses

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

• NHIP is aligned with SDG 3: ensure healthy lives and promote well-being for all at all ages

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• NHIP contributes to SDG 3.8: achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

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• Supplemental indicators for monitoring :

a) 3.8.s.1 Percentage of population covered by social health insurance

b) 3.8.s.2 Out-of-Pocket health spending as percentage of total health expenditure

Performance Audit of NHIP

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Why COA did the audit?

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• Concerns over ACR payment scheme and its ability to improve health care and prevent improper payments

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Audit Objective:

• To assess the extent the ACR has achieved its goals and objectives and the existing control mechanisms have prevented and detected improper payments

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Audit Scope:

• Case rate implementation from CYs 2011 to 2020 involving 61.25 million claims.

Performance Audit of NHIP

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Audit strategies:

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• Created a multi-disciplinary audit team by including IT auditors to facilitate data analytics

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• Remote access to the information system and database enabling the team to continue its work without physically reporting to PhilHealth or to office during community lockdowns.

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• Online survey administration for sample beneficiaries and health care professionals instead of face-to-face

Performance Audit of NHIP

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Data Analytics on high volume of claims from hospitals:

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Performance Audit of NHIP

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

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Performance Audit Office

Turn-around time for reimbursements was reduced from 55 days to 19 days

Control mechanisms were deficient and underperforming due to deficiencies in the design and performance of controls and insufficiency of human resources

Performance Audit Report posted at the COA Website: hhtps://coa.gov.ph/index.php/reports/performance-audit-reports

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Universal Health Care Act of 2018 – enabled NHIP to cover automatically every Filipino Citizen and this is in line with the SDG principle of leaving no one behind

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Issues impacting on SDG 3.8.s2:

• Higher OOP expenses for certain type of benefit packages
• Non-adjustment of case rates
• Incomplete/incorrect information encoded in the system

On track on the attainment of nationally agreed targets

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Performance Audit Office

• Conduct the mandated annual review of the case rates to ensure that the amount of efficiency gains is within reasonable level.

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• Revisit and revise policies implementing the ACR taking into consideration the option of reimbursement of claim based on whichever is lower between the case rate and actual hospitalization charges

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• Address deficiencies in the control design and ensure that controls are working effectively in the existing control mechanisms

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Recommendations:

Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Performance Audit Office

• Annual review of case rates - external review to be contracted and conducted this year

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• Policy change on ACR – the policy on paying which ever is lower when case rates exceed actual hospitalization charges was approved by the Board

- policy implementation review on how to minimize OOP expenses and provide better support value for professional fees and hospital charges

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Actions taken on audit recommendations to enhance SDG attainment

• . SDG audit recognized by stakeholders

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• Use of Whole of Government (WoG) Approach

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• Multi-disciplinary teams

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• Continuous capacity building to enhance the skills of auditors for performance audits

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SDGs ‘ Audit LESSONS LEARNED & CHALLENGES

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• Commission on Audit

Republic of the Philippines

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• Expansion of Performance Audit Office

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• Updating the Performance Audit Manual, which includes a strategic planning process that ensures programs which contribute to the SDGs are prioritized

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• Partnership with USAID and US GAO for capacity building

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• Participation in capacity development projects and programmes of IDI and ASOSAI in collaboration with UN on SDG audits

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• Strengthening of internal communication lines with the need of

external specialized expertise related to SDG programmes and projects

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• Updates on the national government’s SDGs’ implementation

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A Action Plan to Strengthen SAI’s Contribution to Auditing SDGs

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Commission on Audit

Republic of the Philippines

Enabling Partner of the Government in Ensuring a Better Life for Every Filipino

Thank you!