When times are hard, getting sick is not allowed.

From being a tagline of a popular multi-vitamin brand, the sentence above has morphed into a joke among adults who can barely make both ends meet

But for those who are worse-off, those who live below the poverty line – they constitute about a fifth of the Philippines’ population – it is a truism, a reflection of a harsh reality, a reminder of a grim possibility they choose to ignore.

For sure, the Philippine government has a health insurance program that seeks to provide poor patients access to quality health care. The program was established to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all Filipinos, according to state-run Philippine Health Insurance Corp (PhilHealth).

Ideally, poor Filipinos do not have to spend a single centavo for health care, a basic right. But because of rising costs of medicines and doctors’ fees, this is easier said than done. Doctors admitted the assistance given by PhilHealth could not cover all costs and some patients ended up being transferred to other hospitals.

Worse, there were instances when PhilHealth failed to immediately settle reimbursement claims, a situation that may force some hospitals to refuse non-emergency patients.

Insufficient payments

The National Health Insurance Program was envisioned to become the “means for the healthy to help pay for the care of the sick and for those who can afford medical care to subsidize those who cannot.” Under the system, employers deduct the monthly contribution from employees’ salaries and remit them to accredited collecting agents. PhilHealth is supposed to reimburse the charges deducted by hospitals from patients’ bills.

PhilHealth members are divided into seven categories. They are formal economy or those with formal contracts and fixed terms of employment; informal economy, which include self-earning and migrant workers; overseas Filipinos; lifetime members or those who have reached the age of retirement under the law and have paid at least 120 monthly premium contributions; senior citizens or those who are 60 years old and above and are not covered by any of the membership categories; sponsored members of those whose contributions are being paid for by another individual or entity; and indigent or persons who have no visible means of income, or whose income is insufficient for family subsistence, as identified by the social welfare department.

All indigents under government’s household targeting system shall automatically be enrolled and covered under the program. To ensure indigents’ access to medical services, PhilHealth has a “no balance billing” policy, which states that no other fee or expense shall be charged to the indigent patient. This means that indigents no longer need to pay for their hospitalization at any government hospital and selected private medical centers above or beyond the package rate.

But some government hospitals are having a hard time complying with the policy because the hospitalization fees costs more than the amount provided by PhilHealth for the case rate payment.

“PhilHealth will only pay us the case rate. That means, for example, if the patient is sick with pneumonia and the hospital spent P20,000, it will only shoulder P8,000,” said Primo Valenzuela, chief training officer of Rizal Medical Center in Pasig.

“In a complicated case like pneumonia, P8,000? I don’t know how they came up with their computations,” he added.

Each pneumonia patient is entitled to P6,000 to P8,000 PhilHealth case rate payment. Recent studies estimated that the hospitalization costs of patients aged 19 and older range from P25,000 to P90,000. The expenses cover diagnostic procedures, hospital confinement, treatment cost, accommodation, supplies, professional fees, and other charges.

Limited options

Valenzuela said PhilHealth reprimands hospitals if they charge indigent patients, leaving them with no choice but to refer them to other health institutions, a situation that can be harrowing for patients.

“You will just rely on the PhilHealth claim. But if you ask him to buy something, you will surely be scolded by PhilHealth. What will you do? You transfer the patient to another hospital and that is what’s happening,” he added.

Insufficient case rate payment is not the only issue confronting patients and hospitals. If a patient is admitted to a private room, doctor’s fees would apply, making the treatment more costly.

“For instance, if you contracted dengue (virus), you have to pay P12,000 (plus) P3,000 because you have to stay in the hospital for more than a month. If you are under NBB (no balance billing balance) policy, PhilHealth will also pay the hospital P15,000 but the hospital cannot ask the patient to pay,” said Roderick Napulan, a development management officer of the health department.

Valenzuela admitted funding issues and limited resources are making it hard for government hospitals like to cope with the increasing number of patients.

“There’s just always so many patients, and its increasing consistently…The number of cases are unlimited but the resources are limited. I think that’s true for most government hospitals,” Valenzuela said.

Rising reimbursements

Because of costly medical services, PhilHealth has incurred debts to private hospitals.

Previous reports have quoted Rustico Jimenez, president of the Private Hospital Association of the Philippines, as saying that the state-run health insurer’s debt to private hospital has ballooned to as much as P10 billion. The debt was supposedly caused by PhilHealth’s failure to settle reimbursement claims from 2011 to 2017.

PhilHealth vice president for corporate affairs Shirley Domingo denied Jimenez’s allegation in a radio interview last November, saying the health insurer was only processing P338 million worth of claims from 63 hospitals.

In a statement released in the same month, PhilHealth denied it lacked funds to settle its obligations. It also reported a net income of almost P10 billion as of the end of September, higher than the P4.4 billion recorded in the same period last year.

PhilHealth said the financial performance had contradicted the “recycled claim” that it does not have the resources needed to pay the claims of its member hospitals.

“We have again proved to our members and stakeholders, and even to our detractors alike that their funds are not just intact but also performing well, thanks to our unrelenting campaign to improve collections; the growing number of members that religiously pay their premiums; and our performing investments as well,” PhilHealth acting president Roy Ferrer said in the statement.

Benefit payments remained the largest item in PhilHealth’s expenditure at P84.3 billion. Benefit payments refer to reimbursements for services that health care providers have rendered to PhilHealth members and their dependents.

Higher budget

PhilHealth will get P67.4 billion for its National Health Insurance Program this year, higher than its P54.1 billion outlay last year.

The Program is expected to benefit 15.4 million indigent families, 5.4 million senior citizens, 25,514 families under the PAMANA program and 22,709 families under the Bangsamoro health insurance program, according to the budget department.

As of March 2018, the country’s health insurance program covers 98.24 million Filipinos or 92 percent of the entire Philippine population.

“Looking back at the health agenda of the Duterte Administration, which is to continue widening the coverage of the health insurance program, we can see that we are definitely on the right track,” budget secretary Benjamin Diokno said in a statement.

Last month, the Senate and House of Representatives ratified the Universal Health Care bill, which seeks to expand PhilHealth coverage to include free consultation fees, laboratory tests and other diagnostic services.

Funds for the expanded health care program will come from sin tax collections, charity fund Philippine Charity Sweepstakes Office, income from the Philippine Gaming Corp., members’ contributions, annual budget of the health department and government subsidy to PhilHealth.

Lawmakers have expressed hope that the law would solve all problems plaguing the health sector and enhance access to quality health care, a basic right that has remained a luxury for a significant number of Filipinos.


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