PhilHealth Schemes and Things

(Photo from PhilHealth)(Photo from PhilHealth)


     One of the two health issues that made it to the second State of the Nation Address of President Benigno S. Aquino III on July 25 is the enrolment to PhilHealth’s insurance program of 5.3 million poor families identified in the Department of Social Welfare and Development’s National Housing Targeting Survey for Poverty Reduction (NHTS-PR). (The other health issue is immunization which the President uttered twice in passing.) PhilHealth enrolment and its consequent utilization of benefits by indigent families are considered the centerpiece of the Aquino Health Agenda’s Kalusugan Pangkalahatan (universal health care) within three years. That’s by June 2013 already, and time is ticking fast.

     Effective September 1, the DOH and PhilHealth implemented the case rates scheme for in-patient treatment of 22 common medical and surgical conditions. Simply put, Health Secretary Enrique T. Ona said that this scheme is akin to a “pakyaw,” or wholesale system where all the fees are fixed, but for 22 most common cases only and not for all types of cases which will be paid directly to both government and private hospitals and clinics.

     The case rates payment covers: dengue 1 (P8,000); dengue 2 (P16,000); pneumonia 1 (P15,000), pneumonia 2 (P32,000); essential hypertension (P9,000), cerebral infarction cerebro-vascular accident hemorrhage 1 (P28,000); cerebro-vascular accident hemorrhage 2 (P38,000); acute gastroenteritis (P6,000); asthma (P9,000); typhoid fever (P14,000); and newborn care package in hospitals and lying-in clinics (P1,750).

     On the other hand, the surgical procedures include radiotherapy (P3,000 per session); hemodialysis (P4,000 per session); maternity care package (P8,000) coupled with the normal spontaneous delivery (NSD) Package in Level 1 (P8,000) and Levels 2 to 4 hospitals (P6,500); caesarian section (P19,000); appendectomy (P24,000); cholecystectomy (P31,000); dilatation and curettage (P11,000); hyroidectomy (P31,000); herniorrhaphy (P21,000); mastectomy (P22,000); hysterectomy (P30,000); and cataract surgery (P16,000).This is much different from the original scheme of PhilHealth which was to pay for services where rates were based on the category of hospital, length of stay at the hospital, kind of illness and complications, among others.

     An added feature to the new case rates scheme is the “no balance billing for NHTS-PR PhilHealth members admitted in government hospitals for these conditions. This is why Ona encourages indigents to go to government hospitals instead because the scheme does not cover private hospitals.

     The Private Hospitals Association of the Philippines (PHAP) was up in arms over new regulations and warned that patients’ bills would go up. They also threatened to remove themselves from the list of PhilHealth-accredited hospitals.

     In an ABS CBN news report, Dr. Rustico Jimenez, PHAP president, was quoted as saying, “Ang dengue, tests pa lang ubos na ang P8,000. Paano pa yung professional fees ng mga duktor? Ang tatamaan nito yung ordinaryong tao.”

     DOH and PhilHealth maintained their position saying that they have to put a ceiling on payments to protect the funds of members and ensure hospitals do not overcharge.

     Also in September, the DOH and PhilHealth announced its public-private initiative to  encourage more people to become part of PhilHealth and to assist PhilHealth in improving its services. Members are now entitled to discounts for medicines and other health services in some participating pharmacies and shops.