Hospital recovery to hinge on staff availability, collections
HOSPITALS are hanging on as coronavirus surges come and go, but their long-term health will ultimately depend on finding adequate numbers of staff and collecting on their receivables from the national health insurer, among others.
Just before the August wave, hospitals had a brief respite from the frantic days of the March-April surge, allowing some industry associations to reflect on bigger-picture issues ailing their member-companies instead of being preoccupied with dealing with day-to-day crises.
First, a snapshot of where things stood before the Delta surge hit last month: In Metro Manila, the majority of cases was judged to be mild, not requiring hospitalization but merely isolation. But the August surge, thought to be caused by the more easily-spread Delta variant of coronavirus disease 2019 (COVID-19), threatened to overwhelm hospital capacity once again.
Speaking at a Zoom meeting in June, before the Delta surge, Private Hospitals Association of the Philippines, Inc. (PHAPi) President Jose Rene D. de Grano said: “The moderate and severe cases are the ones that are placed in the hospital beds in Metro Manila. More or less, right now it’s around 5% or less than 5% of the total active cases so there is not much.”
At the time, cases in the Visayas and Mindanao were increasing. “They were having the problem that NCR had (in March and April).”
Despite operating under pandemic conditions for over a year, hospitals were still having a problem with manpower, according to Philippine Hospital Association (PHA) President Jaime A. Almora.
Financial problems have also been exacerbated by the nonpayment of coronavirus claims by the Philippine Health Insurance Corp. (PhilHealth), he said.
“But we are coping,” Mr. Almora said in a phone interview, noting at the time that the pause in the coronavirus surge was allowing regular patients to come in for treatment.
This category of patient had largely been shut out by the pandemic because hospitals were swamped dealing with emergency respiratory cases, which required extra care in handling as well as expenses. Staff were also rotated to minimize their exposure, and had to be taken off duty if they tested positive.
Health department epidemiology bureau director Alethea de Guzman said in an online briefing in July that before the Delta surge in August, Philippine infection rates fell by 9% in the two weeks ending on June 26 while the average daily attack rate (ADAR) — new cases divided by population — was at 5.24.
Metro Manila at the time was also classified as low-risk with coronavirus infections declining by 26% in the same period while the ADAR was at 5.01.
Coronavirus cases in Luzon had been falling except for the Cordillera Administrative Region, Ilocos and Mimaropa, the Health department said.
Cases in Eastern and Western Visayas were rising, while Central Visayas plateaued after a sharp decline, according to Ms. De Guzman. Cases in Mindanao had been falling except for the Davao region, where the trend was inconsistent.
However, the Health department flagged the Eastern Visayas, Western Visayas, Davao region and Soccsksargen as “high-risk” at the time. Davao region had a high healthcare utilization rate and critical-risk intensive care utilization rate, while Western Visayas and Cagayan Valley had high-risk ICU usage rates.
Nationally, bed occupancy was at 46.1% out of the total 35,143 beds in 1,272 facilities as of June 30. A total of 870 facilities were at safe levels or less than 60% occupied, 88 were at moderate or 60-69% occupied, 110 were classified as high-risk or 70% to 84% occupied and 148 were critical, according to the DoH’s tracker website.
A total of 55.98% of 3,421 intensive care unit beds were occupied. Around 46.15% of 19,524 isolation beds were occupied, and around 43.3% of 12,198 ward beds were used.
The National Capital Region (NCR) reported a 37.7% occupancy rate during the pause between surges. Of the 159 facilities, 132 were at safe levels, six moderate, 11 high-risk and eight critical.
PROBLEMS, RECOVERY
Mr. Almora said the number of available nursing staff is falling due to migration and a preference for working in government hospitals.
Mr. De Grano said the number of nurses in private hospitals even before the pandemic had decreased by around 30% to 40%. “There are no available nurses right now because
nurses went to the government facilities because they are offering higher salaries.”
Some were afraid of contracting coronavirus and expressed a preference for work in parts of hospitals that were less exposed, he said.
“We are used to working under stress under pressure, but the situation is far from normal,” according to Mr. Almora of the PHA.
Mr. Almora said hospitals will recover as long as problems do not pile up to the point that they are overwhelmed. He added that much depends on the national insurance agency, which has “absolute and total control” over hospital claims for treating COVID patients.
“We hope to recover (with the admission of) non-COVID cases. But the hospitals that have admitted COVID cases have used a lot of resources. So hopefully, babayaran
PhilHealth ng tama (PhilHealth needs to do right by them with prompt payments),” he said.
Mr. De Grano of the private hospitals’ association also cited the cash crunch caused by the payment delays and the drying up of non-COVID cases.
“Private hospitals do not have subsidies like government facilities. So, they rely mainly on patients coming into the hospitals, from the admission of patients and their payments and for the services that they are using in the hospital.”
He said that some hospitals have availed of a debit-credit payment method (DCPM) scheme for their PhilHealth beneficiaries, but the reimbursement rate is “not enough,” claiming a yield of only around 35-36% instead of the 60% promised.
Some preferred to go through the normal process of filing claims which he estimated takes at least 60 days. Mr. De Grano added that payments for 2021 are being released but some hospitals are still complaining that they have not received payment for coronavirus claims for 2020, saying about P20 billion has yet to be reimbursed.
Senator Maria Josefa Imelda R. Marcos in a statement in late June said her office received complaints of at least P26 billion in claims that remain unpaid to private hospitals. She added that the DCPM did not cover unpaid claims from last year and the 60% target amount was not fully settled, citing one private hospital, which received only P430 million out of P1.2 billion in claims, a recovery rate of 36%.
“Complaints reaching our office show that at least P26 billion remains unpaid to private hospitals, while government hospitals are still owed hundreds of millions. Let’s not wait for them to shut down nor leave them ill-prepared to deal with the possible spread of the dreaded Delta variant,” she said.
Ms. Marcos added that hospitals also raised concerns over an online ledger known as the Reconciliation Summary Module, to which hospitals and PhilHealth subscribe. The system allegedly shows that PhilHealth has paid even when the amounts have not yet been deposited to hospital accounts.
PhilHealth on April 8 issued a circular concerning the DCPM, in which it committed to paying 60% of healthcare facility receivables, subject to a 2% expanded withholding tax for eligible private entities.
It was to pay the remaining 40%, also subject to 2% expanded withholding tax for private facilities, “following full compliance with existing claims processing requirements and procedures and full reconciliation of the 60%” initially paid.
This followed an order from President Rodrigo R. Duterte to the state insurer to fasttrack the payment of hospital claims.
Initially, the payment method only applied to hospitals in Metro Manila, Batangas, Bulacan, Cavite, Laguna, Pampanga and Rizal. This was then expanded to high and criticalrisk areas.
In a Facebook post on June 9, PhilHealth said P6.2 billion had been disbursed to 203 public and private healthcare facilities under the DCPM, 114 of which were from the capital region. The payment method is applicable to claims from between March 8, 2020 and April 7, 2021.
The DCPM does not include claims that are tagged as returned to hospitals, denied, endorsed to the Legal Department for further investigation and those paid as of April 7, according to the post.
PhilHealth recognizes the importance of paying the claims to the ability of hospitals to operate, PhilHealth Vice-President for Corporate Affairs and spokesperson Shirley B. Domingo said.
“PhilHealth reimbursements are important... Malaki na ang nako-contribute ng Philhealth sa mga cash flow… ng hospitals (PhilHealth accounts for a major part of their cash flow),” she said in a phone interview.
Ms. Domingo said there are many reasons for delayed payment releases, citing issues in claims processing, which sometimes result in “returned to hospital” claims due to deficient documentation.
The lockdown has also affected operations. “Naapektuhan din kami sa pandemic on our part because marami rin nagkasakit sa amin ng pandemic, na-quarantine because of exposure and all that (We were also affected by the pandemic. Many of us got sick or were quarantined). Right now, many are still… working from home, but they continue processing the claims,” she said.
Ms. Domingo also questioned the claim that the DCPM is not yielding sufficient payments, saying that the regional offices have to reconcile the amounts with hospitals to account for claims that are returned to hospitals or denied.
“That’s why our regions are doing reconciliation with the hospitals on the actual amounts payable,” she said.
She said PhilHealth is monitoring the turnaround time of the regions and has found that some meet the 60 days’ deadline for regular processing.
“Iba-iba ang turnaround time kasi per region, lalo na smaller regions, mabilis magprocess ng claims, so depende ’yun sa region (Processing times vary, especially with smaller regions, which are faster)” she said.
OVERWHELMED
Mr. De Grano said that everyone should be prepared for some kind of epidemic, but the situation with the coronavirus “went to a magnitude that we cannot really handle.”
“They (hospitals) were overwhelmed by the magnitude of this pandemic,” he said.
“Lessons learned here is for the hospitals to really save... you cannot rely on PhilHealth or the government to pay you,” he said, noting that it takes 60 to 120 days for PhilHealth to pay up in general, with further delays for coronavirus cases.
He said that a year’s delay in the release of claims is not survivable for small hospitals. Some hospitals had to downsize or reduce working hours to avoid layoffs, while others took out bank loans to survive.
Mr. De Grano said the government is trying to balance its priorities between reviving the economy and dealing with the public health emergency.
He said a sense of complacency has set in when it comes to following the minimum health protocols.
“I think if… we are able to vaccinate a majority of our people, then we will no longer get into a situation where the hospitals are overwhelmed,” Mr. De Grano said.
VACCINATION
Mr. De Grano said the speedy rollout of vaccines will be key in heading off surges.
“If are able to do that, and then if we attain what herd immunity, even for 40% of our population, I think that will be a big, big help to our healthcare system. Eventually, we will be able to overcome this pandemic,” he said.
As of Aug. 5, around 23.2 million vaccine doses had been administered, with 10.7 million fully vaccinated.
Mr. Almora also said broader vaccination will help hospitals recover.
“That is the only solution,” noting that prevention is the best approach.