Philhealth vs Hospitals: What the current conflict means (Second of two parts)

CEBU, Philippines - As the Philippine Health Insurance (PhilHealth) endeavors to meet the demand of its partner hospitals for timely reimbursements, the Private Hospitals Association of the Philippines Inc. assures that its members will continue to honor the PhilHealth membership of patients – at least until this month. 

Hospitals accredited to PhilHealth earlier threatened to do otherwise due to the latter’s failure to pay the hospitals for six months.

PhilHealth President Alexander Padilla has admitted they are experiencing some problems with the newly-implemented case-based payment system. He says PhilHealth employees are exerting extra effort to adjust to the changes and to eventually speed up the usual 60-day processing of health insurance repayments to private hospitals.

The new payment scheme began in January this year and went into full swing in Central Visayas two months ago.

Meanwhile, the private hospitals expressed hope that the controversy with the insurance firm would be settled as soon as possible or else, PhilHealth beneficiaries might suffer in the long run.

Rev. Mequias Camba Jr., VCMC Chief Executive Officer and Administrator has said it  might be more beneficial to parties concerned if PhilHealth just scrap the all-case rate scheme since it is deemed detrimental to the financial state of private hospitals.

Atty. Karisma Agraviador, PhilHealth-7 public relations officer, pointed out, however, that PhilHealth will only reimburse medical expenses of a patient based on the final diagnosis given by the doctor.

 "We will determine what is really the main condition for the admission of the patient, what causes the hospital charges to be that high and what prolonged the stay of the patient inside the hospital. And of course, the hospital shall have to treat the patient prior the discharge," she says.

 She adds that the doctor is responsible for recommending medical tests that a patient needs to undergo.

"Di man unta madugay ang patient sa hospital if dali ra ma-assess sa doctor ang iyang case. But there are cases in which the patient need not to be admitted in the hospital but was forced to be confined kay dugay man ma-assess sa hospital iyang case. Puwede i-outpatient ra man unta. So we already encounter a problem sa diagnosis pa lang daan," she says.

 A member is entitled to a maximum of 45 days of confinement and all qualified dependents of the member share another 45 days benefit per calendar year.

There are 56 government and private hospitals accredited by PhilHealth in Central Visayas, 44 of which are in Cebu. Of the 56 hospitals, 33 are privately-run and 20 are in Cebu.

 Region 7 has 4.7 million PhilHealth members and dependents with 2.9 million in Cebu. Of the 2.9 million, 1.3 million are members and 1.6 million are dependents.

Brighter side

Despite the current circumstances, Dr. Eli Belarmino, medical director at the Visayas Community Medical Center, says he holds no grudge against the government-run insurance firm. As a matter of fact, he lauds the conception of PhilHealth since low-income earners and indigent Filipinos could now avail of good quality health care.

 â€œPhilhealth, shall we say, is the best thing to happen to the Filipino patients. Being a PhilHealth member does not mean wala na ka bayaran sa hospital. Naa pa ka bayaran pero, at least, gamay na lang. That is already a big help to our fellow Filipinos. In fairness sa PhilHealth, naa man sila nahimo,” he says.

 He recalls how, in the past, PhilHealth would encourage doctors to have their patients insured with the firm.

“They gave us that hope nga mobayad sila dayon sa mga hospitals if we do that. But they stopped it na. Maybe they were overwhelmed sa kadaghan sa patients unya grabe pud ang utilization,” he says.

 He is hopeful that the new payment scheme would eventually usher in a better partnership between PhilHealth and the hospitals but until then, he remains concerned of the kind of blow delayed payments will have on medical institutions. He fears it would eventually affect the flow of medical supplies and salaries of hospital employees.

Meanwhile, Vicente Gullas Memorial Hospital Medical Director Dr. Leticia Abinuman says that while she acknowledges that being a PhilHealth-accredited institution requires the hospital to offer state-of-the-art medical services to its patients, it may be better for PhilHealth to leave this aspect to the hospitals themselves.

“We are the hospital, we are the provider. We should be the one to choose what insurance companies we will accredit, not the other way around. Ngano sila man ang magbuot nga unta they are the clients. Sila ang mo-apply sa hospital, kami ang mo-demand sa ila,” she says.

 She adds that medical institutions should abide directly with the instructions of the Department of Health and that the government-run insurance firm should not act as the accrediting body for hospitals.

 She admits, nevertheless, that the strict regulations of PhilHealth have prompted accredited hospitals to improve services and equipment.

 â€œBut it should be reasonable,” she says.

What lies ahead

If it were up to him, Camba  says PhilHealth’s system would be redesigned to strengthen its purpose of being the government’s arm for health care insurance. “They really need overhauling,” he says. He calls on government to investigate the current issue.

Senate Majority Leader Alan Peter Cayetano has asked President Benigno Aquino to fire PhilHealth officials but Abinuhan says officials in the regional level are actually performing well.

“Wa man mi problema sa ila. Sayon ra sila duolon. When we ask for them, they are there,” she says.

 He does not agree with firing its officials but Camba says someone must be held accountable in guarding and managing the people’s money.

 â€œThe members have worked for it and entrusted it to them for their safety and future need for ill-health so they have to be so credible and dependable. I agree that some heads shall roll,” he says.

 He urges government to be more vigilant in monitoring PhilHealth operations and in the implementation of the Philippine Universal Health Care Program for all Filipinos, especially for the marginalized sector.

 â€œThese officers must bear in mind that what they were servicing are people who cannot afford and are incapable to pay medical and surgical treatment or financially-disabled,” Camba says.

Abinuman, a PhilHealth member herself, says it is a form of dishonesty when the insurance firm gets a chunk of its members' monthly salaries promptly but does not observe the same promptness in paying hospitals.

Padilla has warned that PHAPi members that will not honor PhilHealth members may face sanctions. He says if this happens, hospital owners would violate the "Performance Commitment" they have executed when they were accredited by PhilHealth.

PHAPi has put its threat on hold but how things will unfold by month's end will depend on how the new system works.

For her part, Vicente Gullas Memorial Hospital Administrator Tricia Ivy Gullas says the hospital will support the decision of PHAPi members.

“Whatever will be the decision of the majority, we will go with it and favor it,” she says,

Belarmino assures dishonoring a PhilHealth membership will be a worst case scenario as far as the Visayas Community Medical Center is concerned.

“That will be the last thing that we will do. There is still hope this will be solved,” she says. — /JMO (FREEMAN)