DOH, PhilHealth defend new policies

by RG Cruz, ABS-CBN News

Posted at Sep 30 2011 05:46 PM | Updated as of Oct 02 2011 03:47 AM

MANILA, Philippines - Health Secretary Enrique Ona and PhilHealth President Rey Aquino on Friday stood by 2 new policies that are feared to limit the availment of benefits of indigent PhilHealth members.

Ona and Aquino met with the Private Hospitals Association of the Philippines (PHAP) and other stakeholders  in a closed-door session .

Ona said the case-payment and case-rate schemes were already implemented at the beginning of September but there were misunderstandings on its implementation.

He said PhilHealth previously paid for medical expenses of members on an item basis, meaning individual doctors are paid and hospital services and supplies are paid separately.

This, he said, caused delays in remittances of payments because it was a complicated process.

"Kaya napaka-complicated, napakadaming items and among other things, ito ang cause of delay ng payment kasi nga maraming items ang being evaluated."

Ona explained that the case payment scheme is akin to a "pakyaw," or wholesale system where all the fees are fixed for some 23 cases only and not for all types of cases.

Cases covered

Among the cases covered are dengue, pneumonia, hypertension, cerebral infarction, cerebro-vascular accident (hemorrhage) (CVAII), asthma, acute gastroenteritis (AGE), typhoid fever, newborn-care package in hospitals and lying-in clinics,  hemodialysis, maternity care package, NSD package in level 1 hospitals, NSD package in levels 2 to 4 hospitals, caesarean section, appendectomy, cholecystectomy, dilatation and curettage, thyroidectomy, herniorrhaphy, mastectomy, hysterectomy, cataract surgery.

The case prices range from P1,750 to as just as high as P38,000.

Ona said this system has been used in other countries. "Napag-aralan na average cost of a case including not only hospital but also professional fees, ginawa ng PhilHealth i-adapt ito. We implemented that for the Philippines because it’s a major change."

He said the system should also expedite payments from Philhealth because the amounts will be easier to predict. "Let's say meron kang pneumonia or acute appendictis, naoperahan ka, pakyaw na ang bayad doon. Alam na kaagad, pag-submit sa PhilHealth ng diagnosis, meron na kagad amount na babayaran sa hospital at duktor."

Complimenting the case-rate system is the no-balance billing scheme. Ona said this applies only to indigent patients  covered by the national household targeting system for the poorest of the poor and patients sponsored by local government units.

Ona said this applies only to government hospitals.

Under this scheme, beneficiaries no longer have to pay extra in case their medical expenses go beyond the amounts covered by the packages in the case rate system.

"Wala nang tinatawag na no balance billing. Ibig sabihin, bayad ng Philhealth. Wala na silang magagaling sa bulsa nila," he added.

This is why Ona encourages indigents to go to government hospitals instead because the scheme does not cover private hospitals.

25 million poor patients to benefit

Ona estimated that about 25 million indigents and at least 3 million patients sponsored by local government units will be affected by these programs.

He thinks that private hospitals won't be far behind in implementing this proposal. "Iyung private hospitals, tinitignan nila rate na iyun. They may do that kung okay sa kanila. Gusto ko lang ipaliwanag na commitment is only sa government hospital. I can be certain there will be several private hospitals who on their own can say i-assume nila additional cost ng sumobra."

Aquino, meanwhile, said they will keep consulting stakeholders on the matter. "Provided sa case payment and no-balance billing, there will be evaluation every 6 months, we promise."

He said they anticipated reactions from some sectors. "We expect this to happen kasi nga there will be some reactions pag actual implementation na."

Private hospitals' concerns

PHAP president  Dr. Rustico Jimenez emerged from the meeting smiling but still refusing to budge on his concerns.

Jimenez pointed out that private hospitals outnumber public hospitals. He estimated about 1,000 hospitals in the country are private, with only 800 government-owned hospitals.

Since the no-balance billing scheme applies only to public hospitals, those in the private hospitals will be put at risk of having to shoulder expenses incurred beyond what is prescribed in the case system, he said.

Jimenez showed a patient at the Medical Center in Parañaque as an example.

Wilfredo Zafe is a stroke patient from Virac, Catanduanes. He was admitted only this week.

Under the case-rate system, he will have to pay anything in excess of the P28,000  prescribed by the system in his case.

Jimenez said he brought up their concerns with the government and he confirmed they agreed to discuss and review these policies further.

However, he maintained that the policies, even if these cover only government hospitals, won't be viable for private hospitals in the long-term because indigent patients will not be able to pay in excess of the amounts for the case rate system.