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

CEBU, Philippines - Thirty-eight-year-old Christopher found himself in the hospital for the second time since 2005 when he was admitted due to stones in his kidney. This time, he’s back due to increased level of uric acid, which made it painful for him to urinate.

An IT technician in a Cebu-based company, Christopher has relied on his Philippine Health Insurance (PhilHealth) card for his medical concerns. His wife and three children also share the benefit from the state-run insurance firm.

Like many beneficiaries, however, Christopher remains oblivious of the brewing tension between PhilHealth and its accredited hospitals across the country. The hospitals have protested the delayed reimbursement on the part of PhilHealth – reportedly up to six months – and threatened not to honor cards of beneficiaries.

As far as Christopher is concerned, he has been paying his contribution to PhilHealth on time as it is being deducted directly from his salary. He then expects to continue receiving the same service from the hospital, especially during emergencies.

“Gamit kaayo sa akong pamilya ang PhilHealth. So far, wa pa man mi’y problema sa ilaha,” he says.

Dr. Eli Belarmino, medical director at the Visayas Community Medical Center, says it isn’t surprising that Christopher was unaware of the situation, considering that PhilHealth members are often the last to feel the impact of delayed payments to hospitals. The first to feel the punch, he says, are the hospitals and accredited doctors themselves.

“Yes, the public are the direct beneficiaries but they will be the last to know and to be affected,” Belarmino says.

Payment

 Rev. Mequias Camba Jr., VCMC Chief Executive Officer and Administrator Rev. Mequias Camba, Jr., shares the hospital has only received trickles of repayments from PhilHealth.

Camba also sits as assistant auditor of the Private Hospitals Association of the Philippines Inc. (PHAPi).

 He says that in the latter part of May, VCMC received as low as P150,000 compared to the P2 million or P3 million the hospital usually received every month in previous years. In a span of seven years, PhilHealth owed the hospital up to P15 million. This is aside from the accumulated P10 million it needs to reimburse the hospital.

 â€œVCMC has not been receiving good payments. It is fluctuating high and low, good and bad. If this is happening to VCMC, I can safely say that other hospitals in Cebu also become victims and suffer the same fate of non-payment from PhilHealth,” Belarmino says.

 Belarmino agrees with Camba, citing that VCMC barely receives P500,000 reimbursement a week, which is lower than the P1 million or P2 million it collected from PhilHealth every week in the previous months.

 â€œUsahay gani di kaabot og P100,000,” he says.

 He also says even PhilHealth-accredited doctors are not being paid correctly by the insurer.

 PhilHealth Circular 35 s. 2013 states that case rate payments cover professional fee and health care institution charges but not limited to room and board, diagnostics and laboratories, drugs, medicines and supplies, operating room fees, and other fees.

 Unlike the procedure case rates, professional fees for medical case rates get 30 percent of the case rate amount.

 Belarmino, for example, is supposed to attend to two patients admitted through PhilHealth a day. In a month, he usually attended to 50 PhilHealth members from whose coverage he usually received P2,000.

 â€œBut I only got paid for six patients. Where are the others?” he pointed out.

 Belarmino says doctors who are certified by PhilHealth are obliged to pay an accreditation fee of P1,500 in a year. If the doctors do not pay on time, PhilHealth can discredit them.

“They are actually very strict. Makalapas ra gani mi, penalty dayon. Pero in-ana sila ka-delayed when it comes to reimbursing the hospitals with the payment. Sometimes, we would joke around that they also have to pay for the interest charges,” Belarmino says.

 PHAPi President Rustico Jimenez earlier announced that around 600 hospitals nationwide are seriously considering not honoring the PhilHealth membership of patients due to the delayed release of reimbursements that have reportedly affected their operations.

 If problems continue to arise, Camba adds, there would be a very high probability that hospitals in these regions will opt to follow an alternative move not to honor the Philhealth card.

 â€œThere will be no doubt that hospitals in Cebu, too, may follow,” he says.

 Tricia Ivy Gullas, administrator of Vicente Gullas Memorial Hospital, says the payment from PhilHealth is “tolerable” for now, as reimbursements arrive in two or three months. Before, the hospital would reportedly receive reimbursement after six months.

As a safeguard, the hospital has required insurance companies to put up a bond of at least P50,000 and up to P100,000.

“If in case di kabayad ang pasyente or ang insurance company, ang bond ang mu-shoulder sa expenses. But as soon as the bond would be exhausted, they already have to reimburse it. Dapat unta gani naay interest if they cannot pay in a specific duration,” Gullas says.

 She says around 90 percent of the total number of patients in the hospital make use of their PhilHealth benefits.

Mayca Reboquio who has been a Philhealth staff for three years says she caters to an average of five to seven patients a day at the Vicente Gullas Memorial Hospital.

New scheme

 PhilHealth President and Chief Executive Officer Alex Padilla admits to a “connectivity problem” in the implementation of the “case-based payments” scheme, hence the delay in reimbursements to private hospitals. He says they are working on addressing the strains and is optimistic to release the payments within 60 days or less.

 Atty. Karisma Agraviador, PhilHealth-7 public relations officer, supports Padilla’s statement, saying PhilHealth itself is still adjusting to the new payment mechanism. She explains that when a system is recalibrated, operations are expected to encounter a bump but this would allow improvements. The new payment scheme was implemented in January and went in full swing in Central Visayas last April.

 Camba argues, however, that what is happening is a form of inefficiency on the part of PhilHealth.

“If there are changes in the system, should they not publicly inform the affected hospitals of their operation?” he asks.

 Agraviador explained: “Naanad sila nga sayo pero among gi-orient ang mga hospitals last year sa possibility nga madugay na ang pag-process because of the new payment system.”

 She says that in Region 7 alone, they receive and process an average of 1,900 claims a day. When they adopted the new mechanism, the local encoders adjusted with the system and produced a daily output of 1,100 claims.

 She adds that they even implemented a three-shift mechanism among their employees to cope with the changes.

“We even encouraged them to have overtime during weekends aron maapud-apod ang claims processing,” she says.

 Three weeks ago, PhilHealth-7 processed 1,800 claims daily. Last week, it managed to process 2,000 claims per day.

 â€œAdmittedly, nihinay gyud ang among production but gradually, nagka-improve among performance,” she says.

 Agraviador also explains that the usual processing of health insurance repayments to private hospitals would take up to 60 days. In the past, she says, turnaround time would be 18 days at the very least and up to 69 days.

Delay not new

 Belarmino isn’t convinced.

He says the delayed reimbursement of PhilHealth to its partner hospitals is a long-standing issue even before the new payment scheme took effect.

 â€œBy law, they are supposed to pay 30 days. More often than not, it is not the case. It will run up to 3 months to one year. Along the way, nag-pile up ang delay and dili na sila up-to-date kon mobayad. Something is wrong even then,” he says.

 â€œBut we’ll give them the benefit of the doubt. Dili tinuod nga wa sila mobayad. Mobayad man but they come in trickles so we are not satisfied,” he says.

 Agraviador clarifies that the delay in reimbursement to some hospitals was not due to misuse of funds but as a result of the updated payment mechanism.

 â€œPhilhealth is doing its best to improve its services to its members and to engage a better working relationship with our partner hospitals,” she says.

 In Central Visayas, there are a total of 56 government and private hospitals accredited by PhilHealth, 44 of which are located in Cebu. Of the 56 hospitals, 33 are privately-run medical institutions of which 20 are in Cebu.

 Region 7 has 4.7 million PhilHealth members and dependents. Of this number, 2.9 million are from Cebu – 1.3 million members and 1.6 million are dependents.

All-case rate scheme

 PhilHealth Circular 35 s. 2013, which discusses the implementing guidelines on medical and procedure case rates, states that only those with indication for admission shall be reimbursed by PhilHealth. It specifies that admission due to the patient’s choice is not included.

 However, the case rates shall be the only reimbursement rates for all specified cases. A case rate is defined as a fixed rate or amount that PhilHealth will reimburse for a specific illness or case.

 These rates shall be the amount to be paid to the health care institutions and shall include the professional fees. Medical conditions and procedures that are not in the list shall no longer be reimbursed.

 Vicente Gullas Memorial Hospital Medical Director Dr. Leticia Abinuman laments on the impracticality of PhilHealth’s all-case system and urges the company to improve its payment mechanism.

 â€œThey have a set of diagnosis that will be paid but how will the hospital know that that is the correct diagnosis that will be paid by Philhealth when in fact the patient still has to undergo examination and management? How will we know what is the diagnosis when the patient is still for admission? How would we know that during or after the patient’s stay in the hospital, that that diagnosis cannot be paid by PhilHealth,” she says.

 Camba also calls on PhilHealth executives to scrap the all-case rate scheme since it is deemed detrimental to the financial state of private hospitals.

 Agraviador defends the scheme, saying PhilHealth shall only reimburse medical expenses of a patient based on the final diagnosis given by the doctor.

 â€œWe 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. (To be continued)