A colonoscopy cum endoscopy at a private hospital cost a total of P67,500: P5,000 for the ultrasound, P25,000 for the hospital procedures, P25,000 for the doctor and P12,500 for the anesthesiologist. The self-employed young professional with no special health insurance (only PhilHealth) could hardly afford this. PhilHealth stepped in for P5,400 deductible from the patient’s bill, 8% of total, but that did not go to her. The 30% of P5,400 is for refund to the doctor of Professional Fees (PF) over what was billed to the patient and 70% is refunded to the hospital on top of what was charged to the patient. For surgical cases, it would be 40% for PF and 60% for hospital costs. Crazy, but it feels like PhilHealth is for doctors and hospitals, and not for patients, because patients don’t see, feel and touch the PhilHealth “refund.” It is like a flat “commission” paid for services rendered by doctors and hospitals — while they would still have the freedom to charge higher than the PhilHealth maximum base rates per the immutable chart of coverable diseases and procedures. Since September 2011, PhilHealth started implementing its policy of paying fixed rates or fixed amounts to accredited hospitals and clinics for 11 medical cases and 11 surgical cases charted under its reimbursement scheme called Case Rates Payment (workingpinoy.com June 2, 2014). Refunds have been cut down drastically from 2003, since deductibles (purportedly for the patient, but actually a “bonus” to doctors and hospitals) have been whittled down. Poor patient!
Wonder how the Philippine Health Insurance Corp. (PhilHealth) will now handle its expanded responsibilities and accountabilities, with the signing into law of the Universal Health Care (UHC) Act, Republic Act No 11223 by President Rodrigo Duterte on February 20, and now running its 180 days (until August) to complete the Implementing Rules and Regulations (IRR)? Senators Sonny Angara and JV Ejercito co-authored the UHC, which grants every citizen health coverage that will supposedly lower out-of-pocket health expenses (philhealth.gov.ph Feb 4, 2019).
The UHC I.D./health card to be issued to all (tantamount to a national I.D.?) will be managed by the new Philippine Health Security Corp. (PHSC), renamed from PhilHealth. The Point-of-Service Program will continue, to enable patients to avail of health care facilities, provided they are confined in government facilities. All are also entitled to an “essential health benefit package,” which includes primary care, medicines, diagnostic, and laboratory tests. It also includes preventive, curative, and rehabilitative services.
The PHSC will be creating supplementary coverage by health maintenance organizations (HMOs) and private health insurance, as well as providing network-based licensing, contracting, and accreditation of facilities (philhealth.gov.ph Feb 27, 2019).
Dr. Roy Ferrer, acting PhilHealth president, revealed that over 100 million Filipinos are currently covered by PhilHealth. With UHC, the remaining six million of the population — contributors to PhilHealth: employed, self-employed or professionals; and non-contributors: unemployed, jobless, retired, will soon be in the National Health Insurance Program, with immediate eligibility to claim the benefits when needed (Ibid.). Contributors — or income earners — will have to pay for their premiums while the government will shoulder the contributions of non-contributors. Funds for the subsidy will be included in the annual General Appropriations Act: from the Philippine Amusement and Gaming Corporation (PAGCOR) — 50% of national government’s share; from the Philippine Charity Sweepstakes Office (PCSO) — 40% of its charity fund, net of documentary stamp tax payments, and mandatory PCSO contributions. Health Secretary Francisco Duque also previously said that increased sin taxes from cigarettes will also be a major source of funding for the policy (CNN Philippines, October 10, 2018).
Many doctors seem to have misgivings about the UHC law. While first nobly affirming their Hippocratic Oath of “not ever turning away, and healing all those who need help,” one well-known gynecologist simply said doctors will just have to live with what the government wants to give the people. Doctors and hospitals have managed well enough under the old PhilHealth scheme, and will adjust to UHC. Indeed, public hospitals and doctors will be swamped with those patients availing of free services, but private hospitals and doctors will maintain their snob appeal and their patients will accede to regular billings while availing of maximum PhilHealth deductibles that go back to the hospitals and doctors anyway — no problem.
Excuse me, there is a perennial problem, one senior pulmonologist with a big private hospital said: the receivables of doctors and hospitals from insurance companies, Health Maintenance Organizations (HMOs) and PhilHealth itself. While the Bureau of Internal Revenue (BIR) has zealously tax-mapped hospitals and doctors’ clinics, and unreceipted transactions and discounted or “donated” (free) services (to relatives and friends) are tax violations, unpaid/unrefunded claims by patients using these insurances must already be reported part of taxable income by the doctors and hospitals. Even the private insurers will now have to parallel coverage with the coverage of UHC, and claims will magnify, as will doctors’ and hospitals’ receivables. There is even the added complication of HMOs not agreeing with doctors’ diagnoses and plan of action (e.g. surgery or no surgery; when, how) as these will impact claims.
Note that the Private Hospitals Association of the Philippine Inc. (PHAPi) has a long-running dispute with PhilHealth on around PHP7 billion to PhP9 billion in supposed unpaid claims owed to about 15 of their member hospitals (pna.gov.ph May 25, 2018). PhilHealth denies this, but PHAPi has warned that its members may halt healthcare services to members of PhilHealth by the accredited hospitals that cannot survive or continue operation due to non-payment of mounting claims from PhilHealth (Ibid.). PhilHealth has at times countered withdrawal of accreditation.
An outspoken orthopedic doctor decries alleged anomalies of hospitals overcharging for services and room charges, and some drug companies “controlling” doctors and hospitals and pushing for prescriptions and endorsements for supposed commissions. Under the UHC law, companies that offer generic drugs, medical check-ups, diagnostic tests, and laboratory services will even be happier with their increased role as supplier for the increased demand from expanded coverage and naturally increased needs and consequent availments.
PhilHealth will be the national purchaser of medicines under the UHC program. This can lower the cost of medicines as these will be bought in bulk (philstar.com March 4, 2019). Assuming there will be no-profit transfer to public hospitals and government health facilities, the amount of purchase will give much power and influence to Philhealth/PHSC, and maybe too much temptation to corruption of weaker-principled functionaries.
Dr. Ferrer says PhilHealth is “raring to go” for the UHB, bragging of P11.6-B in net income in 2018, from premium income of P132.5 billion, 23% higher than that of 2017, from which PhilHealth paid a total amount of P121 billion in health care benefits (philhealth.gov.ph Feb 27, 2019). But Department of Health (DoH) and lawmakers estimate that P257 billion will be needed on the first year of implementation of UHB and another P280 billion in the second year. (The Philippine Star Feb 12, 2019). With the magnified privileges (outpatient lab, rehab, maintenance, even preventive medicine) and total population coverage, the financials will not look as nice for PhilHealth/PHSC. And to count on the multiplier of additional sin taxes would be foolhardy. Even the DoH says that sin taxes have to be increased three-fold to fill up what would be a budgetary deficit to implementing UHC during the first two years. (Philippine Star Feb. 12, 2019). Has government even looked at precariously hanging assumptions about the sustainability of grand-scale universal care at this economically tenuous time? Ah, but elections are coming in May.
Why have not the campaigning politicians thought of declaring to shun contentious pork barrel insertions in the stalemated national budget (at least P75 billion, according to Sen. Panfilo Lacson) to at least help jump-start this ambitious, and laudably more pro-poor assist to uplifting the health opportunities of Filipinos?
Amelia H. C. Ylagan is a Doctor of Business Administration from the University of the Philippines.