Rejoinder to ‘Fake benefits’

‘This is in reaction to the March 5, 2019 column article of Mr. Alex Magno entitled “Fake Benefits” which raised several points in relation to the National Health Insurance Program (NHIP) implementation over the last 23 years. Allow us to address each of these items.

On PhilHealth’s institutional capacity

Through the years, PhilHealth was continuously managed by capable leaders holding various degrees such as lawyers, actuarial scientist and doctors. Each President appointed at the helm has contributed in their own way to what PhilHealth is now. We also have financial, actuarial and management experts within our ranks and in the board who contributes in managing the fund entrusted by our members. In previous years, PhilHealth hired the services of fund managers but due to audit concerns, services were terminated.

I believe that more than experts, what Phil Health needs at its helm is someone with a strong political will to see thru to completion all the reforms it has to undertake and extract discipline and to address all challenges brought about by the different views of internal and external stakeholders.

As to financial stability, in 2018 we have posted a record net income of Pl1.6-B. Premium collections reached P132-B bolstered by a P6.7-B return in interests and investments. Weekly benefit payments in the latter part of 2018 amounted to almost 3 billion per week. We believe PhilHealth will not be what it is today without capable people at its helm.

On the payments for cataract removals

We agree with Mr. Magno that a substantial amount of payment for cataract removals was made in previous years. We have pursued aggressive measures to ensure that our fund is protected against abuses in cataract claims. In 2015, a policy was issued authorizing only up to a maximum of 50 approved requests per ophthalmologist per month, not to exceed ten (10) scheduled surgeries per day. This is to ensure quality surgeries and prevent fraudulent practices. Exceptions are those performed by residents-in training under the eye surgeon’s supervision in accredited government or private health care institution with a Philippine Board of Ophthalmology accredited residency training program.

With the implementation of this policy, there was a decrease in an average of 33% number of claims in 2016 to 2017.

As of Febmary 2019, 22 institutional health care providers and 14 health care professionals were charged in relation to cataract surgeries.

On the alleged P 4.9 B operating loss

Although an initial financial report showed a negative loss at P4.7-B, a review of our 2017 financial statement in 2018 showed a net income of P237 million when all remaining 2017 claims were submitted to the Corporation for reimbursement. We have communicated this with the Commission on Audit (COA) and is awaiting their validation and concurrence.

On pneumonia payments

In one of the lectures held last August 5, 2018 at PhilHealth presented by Rontgene M. Solante, MD, FPCP, FPSMID and a member of the League of Experts, Pneumonia was identified as the 4th leading cause of death and 2nd leading cause of morbidity in the Philippines. It is because of this fact that PhilHealth’s payments to treat this deadly disease may not be labeled as an “unreasonable expense.” Because if efficiency gain is common for hospitals treating Pneumonia, we can be assured of the fact that in other more serious medical cases treated by the same hospital, the case rate they receive from PhilHealth is not enough to cover the expenses. To be able to implement the No Balance Billing for the poor patients, the hospital has to use the efficiency gain they receive for billing PhilHealth for the “simple” Pneumonia cases that they treated.

Based on our statistics, Pneumonia- moderate risk is the number one cause of medical illness for 2017. With the ballooning number of pneumonia claims, the implementation of at least four days confinement or the Length of Stay (LOS) policy was set as reference to assure quality of care services and to prevent fraudulent practices in the management of pneumonia. However in October 2017, the policy was lifted after a thorough evaluation of its implementation. Instead, claims for reimbursement for community-acquired pneumonia will be subjected to pre-payment medical review, and the documentary requirements for these cases shall be requested before payment of claims.

In addition, PhilHealth recently issued a policy employing medical pre-payment review using the Claim Form 4 (CF4) effective March 1 of this year in order to assess the quality of care provided to our members.

On case rate payments

On the subject of benefit payouts, PhilHealth paid P121-B in benefits last year. In 2014, we have employed the All Case Rates (ACR) as our benefit payment mechanism. This type of payment has allowed PhilHealth to improve administrative efficiency and reduce turn-around-time for paying health care providers.

The National Health Insurance Act of 2013 defines “Case-based payment” as a payment method that reimburses health care institutions a predetermined FIXED rate for each treated case or disease. Section34 of the same allows the Corporation to employ case-based payment as a provider payment mechanism.

Case rate empowers PhilHealth members by knowing how much they are entitled to in terms of benefit payment during confinement. It also reduces the discretion in adjudicating claims. Likewise, it allows PhilHealth to effectively impose the No Balance Billing (NBB) policy for indigents, sponsored, and senior citizen members.

According to the 2017-2018 National Health Insurance Annual Report of Taiwan, most of the claims (89 percentile) they receive from the hospitals are paid ABOVE the cost that hospitals incurred in treating the patient. This efficiency gain or gain sharing bonus is used to pay for the excessive resources used in cases wherein the payment is BELOW the cost that the hospitals incurred in treating other patients.

We would like to assure our members that we remain focused on our mission to ensure quality health care for our members. We welcome feedback from members like you, so that together, we can work towards further improving the NHIP for the next generations to come.

We hope that this rejoinder sees print in your publication in the interest of fair and balanced reporting.