Presently, members of the state-operated Philippine Health Insurance Corporation or Philhealth, whether paying or government-subsidized, are only able to avail of benefits once they are admitted to a health facility. At that point, more likely than not a patient’s condition, especially if they are poor, is already severe and treatment will be more costly.

While 92 percent of Filipinos are covered by Philhealth, actual utilization of funds is poor. The main reason for this is unlike other universal health care programmes, the out-of-pocket component is high, around 57 percent, which is too much for majority of Filipinos.

This fact alone explains why most people, especially those categorized as indigent, do not seek medical help when they fall ill and often succumb without ever being seen by a doctor.

A second factor for poor utilization is the lack of focus on diseases that should be given priority through Philhealth packages.

Not in Top 10

Says Dr Anthony Leachon, the top 10 killers in the Philippines, based on commissioned, evidence-based studies, did not match those actually being paid by Philhealth. Cardiovascular diseases (hypertension, ischemic heart diseases, congestive heart failure, among others) topped the list.

As independent director of the Philhealth board [nominated by the Monetary Board], the renowned Filipino health advocate noted that there were 10,000 case rates when he came onboard as director of Philhealth, but “those that mattered by Pareto principle were only 50 diseases.”

He cited that Philhealth pays high for dialysis, cataract operations, caesarean deliveries and pneumonia treatment, yet not one is among the top 10 killer diseases in the country. As a result, it has become open to a lot of fraud.

As example, Dr Leachon mentioned that since caesarean delivery is more expensive than normal delivery, obstetricians are prone to recommending the former in order to get paid more. Another example is having two grades for pneumonia - moderate and severe - the latter which costs twice as much as the former.

He moved to change this by having just one case rate. As compromise, every day of confinement entitles doctors to some additional payment. “But do not give them an option of ‘severe’, because even if it’s a simple case of cold, the doctor will indicate severe. And that opens it to abuses.”

Investing in wellness

To improve utilization of Philhealth funds and ensure it is distributed equitably, Dr Leachon is proposing that a portion of the firm's Php122 billion funding be set aside for preventive health services.

This means the state-run insurer will provide similar services as that of private health insurance companies. Members can be seen to by physicians regularly, and can fill any prescription at municipal or city-operated pharmacies where the cost of medications is subsidized, so it is cheaper, or can even be had for free.

He is also pushing to digitize all patient information so that any doctor in the country who will attend to a patient will have his medical history on hand, through the power of technology.

Under the proposed scheme, every Philhealth member is given a benefit of quarterly consultations (Php200 per check up) and access to a Botika ng Bayan (government-run pharmacies) for medications.

If patients are seen to regularly by doctors, severe diseases can be prevented.
If patients are seen to regularly by doctors, severe diseases can be prevented.

Solution to lack of doctors?

Not only will the plan mean providing wellness or preventive services to every Philhealth member, it should likewise help address the perennial problem of Filipino doctors leaving to work abroad.

He illustrated that if doctors are paid Php200 per consultation, sees 30 patients a day, 5 days a week, they can easily earn Php120,000 a month, which should be commensurate to, or even more than what is being offered for overseas employment. And they won’t have to be away from their families.

“Even if they’re deployed in the provinces, they can go home weekends because plane fares are now affordable and can be with their families often unlike if they work abroad,” he pointed out.

Dr Leachon believes that if the Philhealth operated in this way, the chances of preventing serious diseases among the population will be far better.

As it is, the reason why hypertension and diabetes case rates are so high is because most common folk are unaware they were already suffering from these health conditions.

True universal health coverage

“Most Filipinos are afraid to go to the doctor for wellness because they have no means,” he rued.

Dr Leachon noted that only those well-off in life can afford to see a physician because they have HMOs and savings on top of Philhealth coverage. This is reflected in the [Philhealth] utilization rates of 88 percent for the middle and upper classes, compared to just 33 percent for those in the lower income class.

But to institutionalize such a system requires board approval, and Dr Leachon acknowledges it will be a tough battle to convince other members to see things the way he does and support his proposal.

Perhaps, when the Universal Health Care Coverage Act is signed into law that may be a possibility. Under the proposed law, which congressman had approved on third reading, the Philhealth will be transformed into the Philippine Health Security Corporation.

Under the law, membership will be categorized into two - those who contribute premiums and those subsidized by government, which is the bigger bulk of the population. This is the present set-up although there is no actual delineation between paying and non-paying members as both are entitled to similar benefits.

For Dr Leachon, an honest-to-goodness universal healthcare coverage means not only being able to cover every single Filipino, but for benefit packages to be robust enough that it can respond to health care needs from ‘womb to tomb’, and that members have minimal or more preferably, zero co-payment, when they are hospitalized or treated and avail of any Philhealth package. MIMS

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