Below is one thread in the facebook wall of a physician friend, Dr. E, a month ago. While he allowed me to post this exchange in his wall in my blog, I did not get the permission of his other friends who contributed to the discourse, whom I think are mostly physicians too. So I just show their first name initial. What is important here are the insights and frank discourse among these young doctors. Here they go.
Nurse: Doc, may referral po sayo si Dr.___. For surgical consult po.
Doc: Saan ba nakaadmit yan? Kung sa PhilHealth Ward yan, hindi ko tatangapin. Pass muna ako...
(Because of PhilHealth stinginess on the professional fee of physicians, the patients are more disadvantaged.
Nurse: Doc, there’s a referral for you from Dr. ____. For surgical consult.
Doc: Where is the patient admitted? If in PhilHealth Ward, I won’t accept, I’ll pass.)
B: I think it is the greed of doctors kaya nadedehado si Juan.
E: but that's in real life...
M: Di naman sa greed, but with unjust compensation, doctors would opt not to operate lalo na kung difficult cases, the new Philhealth scheme doesnt take into account case difficulty. Di ka na properly compensated, mas malaki pa risk sa license mo, pagod ka pa. I dont think this is in the best interest of the patient. It takes forever for Philhealth to pay the MD and hospital, and only an instant to disqualify patients na may minor delinquencies sa continuity ng payment.
B: The new case-mix payment scheme is designed to contain unnecessary costs in patient management. In a purely fee-for-service scheme, there is much room for abuse. In many cases, doctors would increase their fees so they will get a higher compensation, resulting in high co-payment/out-of-pocket payments from patients who pay the balance. What really is "enough" compensation especially for surgeons? how much is "enough". difficult to say as many vary their fees according to the patient's ability to pay, and the doctors financial "needs" as well. Prices of surgical procedures should be standardized, with a ceiling price. bec such things are easily corrupted by greedy doctors.
Still, Philhealth does not force doctors to accept such patients. The direction now is to implement an "all-or-none" policy. Doctors can either accept ALL philhealth patients or NONE at all. What is "just compensation" how much is this?
B: I agree on one thing M, Philhealth's policy in disqualifying patients in need should be reformed. But in a any shared-risk scheme, patients also have the responsibility to contribute. or perhaps, the LGU should implement its indigent program better. We all have to put our act together to achieve universal health care.
E: If PHIC won't pay, then the patients will pay the doctors. As in the case of one surgeon I know, his PF is 25K for chole. Kung magkano lang ibabayad ng Philhealth, madadagdagan ang out-of-pocket ng patient para mabuo ang 25K. Now, kung mas mababa ang PHIC payments sa doctors, sa patient pa din mapapasa ang burden... And that's what happening. That's based on my observation. Imagine sa cases ng CS deliveries...
B: That is why, I believe it should be ALL or NONE. again this brings me to the question, how much is enough?
E: Like Medicine is considered as a science and an art, there's no definite answer to your question, B. Very subjective ang cost ng healthcare. Difficulty of case, the amount of time the doctor will spend on the patient, the risk of having management failure, etc... Iba ang enough sa neurosurgeons sa enough sa family physician... Iba ang enough sa doctor in Manila sa enough sa doctor sa barrios. Madaming factors.
B: It is difficult, but like any other form of expenditure, it should be standardized somehow. How else can we protect the patients from doctors who overcharge? This is NOT impossible. Our brod, Dr. Pagtakhan, parliament of Canada, implemented such standardization. This is necessary in the standpoint of policy and health financing in a national scale. We can not do long term planning if expected costs vary significantly. also, the inherent knowledge asymmetry of patients and doctors, make this problem even worse
E: With our culture, I think even with that new PHIC policy and standardization, patients pa rin ang sasalo ng burden. PHIC will minimize its expenditures, and patient will shoulder more out-of-pocket payments sa PF. Panalo ang PHIC, panalo ang doctors, yun patient ewan ko...
B: The basic premise of standardization is that, there are cases that are easy and those that are difficult, but such will even out. just like in statistics, if you standardized the variables from a given point estimate, the costs and work evens out.
Agree. Doctors always win in terms of patient care. Sadly, it should be the patient. A Philhealth ALL or NONE policy, i believe should be implemented.
D: Your issues with PhilHealth are valid, and we are working to increase the support value paid by PhilHealth to make it more substantial. The case rate payment for the 23 medical and surgical cases, for a start, is meant for the Sponsored Program members (indigents whose premiums are paid by the national government or local government) to be accompanied by no-balance billing in ward admissions in government hospitals. In the case of private hospitals, they can opt to charge additional out of pocket. I'm aware of the issues of the private hospitals, but we can think of it this way: the case rates is an assurance that they will get something from PhilHealth for serving these poor patients who often give promisory notes in the past. The Secretary of Health has commissioned a study to determine the reasonable and fair PF for doctors (as the PF is very variable, even for the same specialty). We are also working on the supply side (meaning improving government hospitals to prepare them for the increasing number of PhiHealth patients.
K: Unless there is an commensurate increase in the health budget, that will not happen. No matter how many studies are conducted, it will boil down to this government's priorities. And I am not at all hopeful.
D: The 2012 health budget has been increased by 30% to P 44 billion from P 33 billion in 2011. Also, the administration has certified as urgent the bill for restructuring the excise taxes for sin products, which, if passed, will give P 50 billion to DOH and PhilHealth on top of what they are receiving now. True, many more things have to be done. Let's give this administration a little more time.
K: I am waiting. But am not holding my breath. And that increase, while appreciated, is not sufficient. Health still doesn't seem to be the priority, just like the previous administrations.
E: Agree with K.
B: Thank you D for your inputs. Such a study on PF is a very good move. I agree, we should give this administration a chance. Such issues are not solved instantly.
K: We all know it's not done instantly. But if it's not prioritized, it'll never get done. At least not in a manner that would be beneficial to the public.
M: Philhealth sucks period. Good thing most of my procedures and operations are not covered by philhealth. For those covered by Philhealth, i usually dont charge these patients at all, my belief is if they had to invoke Philhealth, baka naman talagang nangangailangan. I admire your optimism B, you have a lot to experience pa, perhaps in time, makukuha mo ibig sabihin namin.
B: Agree with K. It is a challenge especially working with a devolved system. we have to find ways to engage the LGU and the doctors.
To M, yes i have much to experience especially in medical practice. But for you, i also recommend seeing things in a more macro perspective. important to have a grasp on how policies are formed and implemented as well as the intricacies of the different building blocks of the health system vis a vis, working within a democratic framework.
B: Really difficult to implement radical reforms in health. it is not enough that health be prioritized by the national government. it takes time to reconstruct and establish systems. For the first time, we have a president that really does prioritize health. but still, madami ang kalaban at hadlang. i agree with D, we should give such initiatives more time.
Nonoy Oplas: Why not liberalize further the HMO industry? Sickly people should have two health insurance, one govt (PHIC as it is mandatory anyway) and one private so when they get hospitalized, they have 2 sources of payment. HMOs also generally give annual check up, which is preventive. Better that patients would have some idea what will hit them later while they are not yet sick.
E: TRUE TO LIFE SCENARIO 2:
Dahil sa "new" PhilHealth Policy sa doctors on their PFs, lalong nadehado ang kawawang Juan.
Nurse: Doc, may pedia patient po dito sa ER magpapaadmit daw po. Kayo po kilala ng parents kaya kayo na lang daw po doctor nila.
Doc: Saan iaadmit yan? Gusto ko sa semi-private room at least ha. Hindi ako tumatanggap kung sa wards. Kung sa PhilHealth Ward yan, sa ibang doctor na lang nyo ipasa.. Hindi na naman ako mababayaran nyan kahit panggasolina man lang e.
(Because of “new” PhilHalth policy on PF of doctors, patient Juan is more disadvantaged.
Nurse: Doc, there’s a pedia patient here at the ER, the parents know you so they want you to be their physician.
Doc: Where is the patient admitted? I want in a semi-private room at least. I don’t accept patients in Wards. If in PhilHealth Ward, please refer to other doctors. I won’t be paid even for gasoline.)
J: anlaki ng problema ni dr.,ms importante ang mbyaran kaysa mgserbisyo sa bayan:(
E: Yeah. That's the sad reality here. And hoping Philhealth will compensate for the patients, it does not. Or if it does, not enough for most doctors.
P: the sad thing is, Philhealth wants doctors to be benevolent, to give service, all doctors want is a JUST COMPENSATION not an extravagant COMPENSATION but a JUST COMPENSATION. Kung talagang walang pera ang patient at kailangan niya maadmit, many doctors have waived their PF's in the past. some even shell out (we gov't doctors have done this too often naman), pero kung may means ang pt wala namang lukuhan
Case in point (got this discussion from several hospital OMS meetings), Philhealth pays for cataract operation for ONE EYE, if the operation for the other eye will have to be compensated, the pt will have to wait for 90 days for the other eye. OPHTHA says, that is CRUEL practice because the pt will complain (one eye is clear, the other is blurred), Philhealth answers: di operahan niyo na iyong 2 sir, tulong niyo na lang sa pt.......SEE!
Nonoy Oplas: With those additional PHIC members (5.2 M households ba yon?) to be sponsored by DSWD, DOH, etc., more membership means more disappointment. Ako naranasan ko personally, mag-file lang ng reimbursement, 2-3 hrs ang pila. To pay PHIC, they want instant, up to date payment. To claim from PHIC, they want you towait 2-3 months or more, at a low reimbursement.
See also, Part 7: Deregulate PhilSick, October 9, 2011, and
Part 8: Alternatives to PhilSick Monopoly, October 13, 2011