Tax Cut 17: BIR vs. Physicians

The Bureau of Internal Revenue (BIR) made this paid advertisement that appeared in several national newspapers last weekend I think. 

Posting below some comments by doctors expressed in facebook, posted on my friend Dr. Jed Inciong's fb wall, except those from change.org petition and Dr. Calimag. My own discussion at the end. Other posters/images are also posted in fb, copy-pasting them here.

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(1) Change.org Petition (around March 2, 2014, initiated by Minerva Calimag)

The medical profession and all physicians are always portrayed as tax evaders by the BIR. The recent BIR Ad that appeared in the Manila Bulletin is certainly discriminatory of the medical profession. Many of us physicians pay our taxes diligently...should the indiscretions of a few be invoked to penalize the entire medical profession? Many physicians also work in the countryside and they are often overworked and compensated less...this overgeneralization on the part of the BIR certainly maligns the medical profession. We demand that the BIR retract this Ad and issue a public apology in all newspapers for this act.

(2) Butch Tamesis, March 4, 2014

This picture shows the PHYSICIAN in general as a burden to the TEACHER, a representative of the MASA. I wonder if the BIR has really thought about this carefully? BIR is actually inciting the masa to revolt against the doctors and blame them as the cause of their poverty. PAMPABIGAT KAMING MGA MANGGAGAMOT SA MGA MAHIHIRAP! 

Does BIR honestly believe this? I will not repeat what my colleagues have said already against the BIR, but just enlighten you about my sentiments. 

In plain language, I am saddened by your portrayal of me as a burden to the society. After so many years of hard work, and sacrifice to help Filipinos (in general), I now live comfortably, able to sustain my family's needs. And this is how you treat me, as a burden to society!? My parent's left me with a wonderful name, a name I am constantly taking good care of. After my father died, the clinic he left was in shambles as his practice had diminished since he got sick. My sisters and I slowly picked up the pieces and built it back to its old glory. The taxes we pay the government ( yearly business tax, machinery tax, real property tax, tax on improvement, garbage tax, sanitation tax, fire and hazard tax), monthly SSS, Philhealth, Pag-Ibig contributions, VAT (not ours anyway since we collect it for the government) is so much that we barely have savings for the clinic on infrastructure improvements.

My clinic is a medical clinic, not a business enterprise, and yet the instruments to make my skills viable is taxed so much that I have no way of recovering the cost unless I charge my patients for its use. A lot of times I don't charge my patients since they cannot afford it. Medicines I prescribe are also taxed exorbitantly by government (i thought the government is pro people?). Electricity and water, and my gasoline expenses have been constantly going up. I am forced to buy electric fans and air conditioners to make my patients comfortable. That adds to my cost of electricity. And you Commissioner Henares and the BIR look at me as a burden to society???!

I have nothing else to say to you, no threats, no dirty finger, no nothing. At my senior age, I am no longer as violent as I was when i was younger since I saw the futility of being a hot head. I am done with that. But I would HUMBLY and RESPECTFULLY ask you to take a second look at this disgusting picture you have portrayed my profession to be. Please take it back because it slaps every physician (guilty or not) on the face. Prosecute these erring physicians, businessmen, lawyers, etc. but please, do not generalize because even JOSE RIZAL OUR NATIONAL HERO IS ALSO GETTING THE HEAT.

My comment comes from the heart, and I feel it every time I read it. Considering the amount of time I spend treating and caring for my patients, sometimes to the point of giving them free consult (in the clinic, by text, or by phone call anytime of the day,or by email) and medicine if they cannot afford it, I get this distasteful ad from BIR. I cannot NOT take it personally!

And the comments of some people against the doctors also hurt. But it does not matter. What matters most is one, our guilty colleagues must change their ways, and two, BIR must also take it back.

(3) Jed Inciong, March 3, 2014

Much like the persecution of jews in Nazi Germany. Our Doctors are being made "whipping boys" and scapegoats for a flawed income tax collection system. Our physicians are being portrayed as contemptuous cheaters.

All said, it pains me to admit I may have made the wrong choice to stay and practice medicine here in my beloved "Inang Bayan" katangi-tanging Pilipinas!
Ninais na manilbihan sa mga kababayang nangangailangan, kahit na higit na mas malaki ang kikitain sa ibang bayan. Dahil sa pagmamahal sa Bayang tinubuan!

Stem Cell 1: PhilHealth to Cover SCT?

I was following the stem cell treatment (SCT) controversy in the Philippines recently.  The Philippine Medical Association (PMA) and the Philippine Society of Stem Cell Medicine (PSSCM), both headed by Dr. Leo Olarte, vs the 21 other specialized medical societies. The former group says stem cell treatment can cure many diseases, the latter camp says it is not true, that stem cell is proven only for bone marrow transplant and blood-related cancer, I think, and that stem cell in other diseases are still under clinical trials.

But one problem came up when DOH Secretary Enrique Ona has generally sided with the PMA-PSSCM camp and even castigated the 21 medical societies for questioning the latter. Sec. Ona is an Honorary Chairman of PSSCM.

Today, I posted this news story from the Philppine Star and posted in the MeTA Philippines email loop. The images I got from the web, I just added them here.

http://m.philstar.com/314191/show/9e9e9bca3e86ccb9a19ca1f3e38608c9/

By Mayen Jaymalin
 MANILA, Philippines - Ordinary people may eventually have the chance to undergo expensive stem cell therapy.  

Health Secretary Enrique Ona said the Department of Heath (DOH) is looking at the possibility of including stem cell therapy in the benefit packages of the Philippine Health Insurance Corp. (PhilHealth) if the medical sector accepted it as a standard care.  

“Our dream is that when this type of therapy already has a standard of care, its cost will definitely go down. By then, hopefully, (PhilHealth) can offer it already,” Ona said.            

He expressed belief that stem cell therapy has the potential to cure diseases such as cancer, autism, diabetes, stroke, liver disease, spinal cord injury, Alzheimer’s disease and Parkinson’s disease....

Stem cell treatment soon to be covered by PhilHealth? Even if it's still under clinical trials for many diseases? And such treatment is not cheap, many practitioners there charging 6 digits, even 7 digits for their rich patients.

If this will push through, ubusan ng pera yan. What's next, PhilHealth will raise the annual premium of members because funds are running out fast? 

If we want UHC, government, the DOH and LGUs in particular, should focus on primary healthcare, in fighting communicable and infectious diseases, and childhood diseases. If people want stem cell treatment and risk their lives and money for the promise of miracle, let them spend their own money, why drag along pooled fund, especially that people are forced, coerced and arm-twisted to contribute to that fund by law?

A lot of distortions in healthcare and other social issues are often initiated by the government itself.

I just hope that such PhilHealth plan will be junked. Or they want another public clamor against it, ala anti-pork barrel robbery movement?

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Three members of the Council commented:

(a) From Leonie Ocampo of PPhA:

How sad of our DOH to be supporting an initiative and/or treatment not proven by clinical trails yet, more so planning to even put this into the Philhealth benefit package. 

Philippines with its limited resources must FOCUS in the MUST DOs in health care delivery. A lot of problems from procurement, handling and storage, distribution, prescribing, dispensing, administration and monitoring of patients are still into a lot of problems and need government attention to manage and control with the right structure and processes; then here is the department tasks to put all of these in place going to something not proven yet . . wow, I could imagine how much of the people's money will be wasted again. 

Yes, I agree with you Noy, FOCUS should also be given first and foremost on primary health care . . . right structure, right processes, right people and the right resources identified and provided. Let's stop talk, talk and talk but let us start to act in the right direction, sa tuwid na daan. You know what I mean.

(b) From Doc K

Dear all, Doh did not say at anytime that phic will cover stem cell.  Sec Ona has not sided with any groups. Pls do not believe all newspaper reports. Ask why these misleading news are surfacing over the last month.

(c) From Doc Delen:

Dear Nonoy,

Very well said!!!  I totally agree with you!  Really, the priorities of this government is something that we should question.  They are not looking at the needs of the vast majority of the Filipino which can be easily addressed if we put our money on public health and primary health services.  Primary health care is an approach that is not being espoused by the DOH when in fact PHC continues to be the backbone of good health strategies.  Secretary Ona, whose experience is very hospital based, prioritizes tertiary care and hospital centered care which is more expensive.  Certainly, if the government's budget for health is directly given to primary care services, improving the local health center facilities and making health care, including medicines, more available and accessible, then we do not have to have Philhealth that still screens what can be supported or not.  People will now patronize the health centers and exercise their right to health.  This will improve their health seeking behavior and  know that they can avail of services immediately.  They need not wait for their condition to worsen, which is what is currently happening, necessitating a tertiary care consult.  Then, eventually, we can have more healthy people who can now be more productive and contribute more to the economy of the country (but of course there should also be concomitant changes in the economic and political spheres as in providing decent and justly paid jobs, humane housing conditions, good nutrition, good education, etc).

It is appalling that Secretary Ona can think of stem cell therapy first to be included in a Philhealth package before he thinks of improving our basic health care services.  Stem cell therapy is very new and still under study and we should not deceive the people and worse, make money from them as indeed this is a very expensive intervention.  And to use our people's money for this is truly something we should not allow!

Thanks Nonoy for your very good insights on this issue.

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See also:

UHC 18: DOH Budget, Healthcare Deregulation and PharmaWealth, August 08, 2013 

Drug Price Control 37: Four Years of the Policy, August 16, 2013

Rule of Law 21: Fake Stem Cell Therapy and Fake Drugs

* This is my article today in thelobbyist.biz.
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The recent stem cell scandal in the Philippines is another proof that many government agencies are getting busy with so many functions and expectations, spreading their resources thinly, and become distracted if not blinded in implementing what should be their primary mandate.

The Department of Health (DOH) and the Food and Drugs Administration (FDA) are busy with various concerns including those that are better left to the private sector and civil society. And that is how fake – or at least unlicensed and unregistered -- health professionals and medical practices, fake or substandard medicines, untruthful ads on other health products and food supplements, are able to proliferate.

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These are products and services that can be fatal to patients, and both the DOH and FDA seem to be weak on this. Concerns like monitoring and implementing politics-driven policies like drug price control, penalizing small drugstores that cannot upload the electronic drug price monitoring system (EDPMS), can distract them from more important function of going after those fakes.

The old controversy on stem cell therapy was once again highlighted when the Chairman of the Dangerous Drugs Board (DDB), Antonio “Bebot” Villar, went public to complain that after undergoing the treatment to improve his condition – weak body, pain in the bones – the opposite happened. He suffered more difficulty in walking after such treatment.

The stem cell "therapy" was (a) done by foreign physicians (German and Thai) assisted by two Thai nurses, and (b) venue was not a health facility but a hotel, Edsa Shangrila Hotel, done last June 9, 2012. He paid Euros 16,000 for that treatment that produced nothing or even worsened his condition.

Foreign physicians – and many other professionals – cannot practice in the Philippines because of the ban provided in the Philippine constitution. This is one ugly aspect of our charter that needs to be amended and removed. That is why those foreign or non-accredited physicians are doing their practices inside hotels or mountain resorts or spas, where they can hardly be noticed by some government regulatory agencies.

I attended the media briefing by the Philippine Medical Assocaition (PMA) at Rembrandt Hotel last Thursday morning, hosted by the Liga ng mga Brodkasters ng Pilipinas Inc. (LBPI). PMA President, Dr. Leo Olarte said that such  treatment is generally safe if (a) done by accredited physicians, and (b) stem cells should come only from humans, from the patient him/herself especially, and NOT from animals, plants, fetus or embryos of dead babies. He suggested that perhaps what those foreign physicians may have given DDB Chairman Villar was just dextrose or ordinary water.

Mr.  Villar put himself in public ridicule because he dealt with those two abnormal circumstances. But  his act of coming out to warn the public against fake stem cell treatment is good and commendable.

There are crooks and opportunists everywhere, poor and rich countries alike. That is why it is important that the main function of the government is to promulgate the rule of law. Strictly implement laws against stealing, murder, abduction, counterfeiting, etc. When government moves into the function of endless redistribution of income and assets, the primary function is often neglected. And that is where criminals strike, they know that government is busy somewhere else.

Like when our policemen are busy flagging down motorcycle drivers without helmets, or their helmets do not bear DTI sticker; or flagging down color-coding cars, or "colorum"vans that transport office workers to their residential areas. When policemen are busy with these shallow and often extortionary concerns, the real criminals -- thieves, pickpockets, murderers, carnappers, kidnappers, etc. -- are relatively free to do their work.

In one report in rappler, it said, "The Philippine Medical Association earlier said 3 government officials died of complications from stem cell treatments done in the country by non-licensed practitioners." The report could be referring to former Congressmen Pedro Romualdo of Camiguin and Aumentado of Bohol, others.

It is not clear if those government officials died because of the stem cell therapy itself, or their old disease has further advanced to more serious stages and the stem cell therapy was either ineffective or unable to arrest the deterioration of the old disease.

Nonetheless, fake physicians or fake medical practices, fake medicines, they can kill. Or at least they can worsen a patient's condition and hence, make healthcare even more messy and more costly. The DOH and FDA are sometimes clueless that these things are happening more commonly. The DOH for instance issued an order about stem cell treatment only last month, even if these things have been going on for many months or even years.

Government should focus on the rule of law, not on functions that are better left to the private sector and civil society. Drug price monitoring and comparison for instance, is NOT a primary function of the DOH. Even ordinary people themselves can do that -- compare the prices of Mercury vs Watsons vs The Generics vs Rose vs other drugstores. But ordinary people cannot easily detect which medicines are real or fake, which ones can cure and which ones can kill. This function will require laboratory testing, will require lab and medical technologists. That is where the government can ffocus its resources.

Many NGOs, media, politicians and other pressure groups are part of the problem because among their focus is how to demonize the multinational pharma companies. Thus, there are policies like drug price control, EDPMS, IPR and patent tweaking, and so on.  The issue of fake drugs, fake ads in various health products and food supplements, pharmacovigilance and fake medical practitioners often take a back seat.

If existing laws against such fakes are not properly controlled, then more fake stem cell treatment and other illegal medical practices, fake medicines, will happen or proliferate in the country.Bottom of Form

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See also:
Rule of Law 17: Justice Without Discrimination, October 18, 2012
Rule of Law 18: Damaso and Carlos Celdran Conviction, February 04, 2013 
Rule of Law 19: How to Strengthen RoL?, March 25, 2013 
Rule of Law 20: PNP and Rule of Men, April 21, 2013

Health Transparency 6: Physician Protectionism

Nearly 3 years ago, I wrote this:
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Physician Protectionism

July 24, 2009

My clubmate in Rotary, a board member of MG Thinkers and a physician friend, Dr. Jed Inciong, wrote about a certain bill in Congress that imposes what can be considered as "physician protectionism".

Jed said that certain elitist specialty societies and medical practioners who belong to private associations affiliated with the Philippine Medical Association (PMA), are now moving to corner the practice of specific aspects of medical practice in pushing for the Medical Integration Bill, House Bill 5575. Jed added,

In the guise of moving into self-regulation of the practice of medicine, the PMA follows meekly in the dictates of the specialty societies. What the House Bill actually aims for is to limit specialty practice to only those that these specialty societies approve. But the reality is these PMA affiliates are not the only "umbrella organization" of specific medical specialty practice. An example would be that there are 2 or 3 more umbrella organizations for the practitioners of dermatology not belonging to the derma society which is affiliated with the PMA.

If this bill becomes law, it shall discriminate against the vast majority of physicians practicing outside the major metropolitan Philippine cities. Even more so, it shall compromise the practice of the majority of physicians employed in government hospitals outside these same Metro areas.

It was the first time I've heard of this issue, I thanked Jed.

Protectionism -- only us, no competition -- by so many professions in the country is institutionalized in the Constitution itself: engineers, architects, lawyers, physicians, nurses, accountants, etc. are reserved only for Filipinos. Filipino doctors and nurses can practice almost anywhere in the world but foreign doctors and nurses cannot practice here! Talk about hypocrisy and double standard.

Now among Filipino physicians, there is this physician protectionism proposal in Congress. It never fails. People who have some protectionist, even evil, plans always run to the State.

In a free market environment, patients and the public have the freedom to choose who are the doctors and health professionals who can treat them. This pressures the health professionals and establishments (hospitals, clinics, HMOs, etc.) to have good professional reputation and good corporate integrity. They may be expensive but there is good quality of service attached to their names and patients hold on to that image.

No government coercion needed here, by forcing patients to seek treatment only to physicians affiliated with a particular medical association or society. And physicians outside of that medical association will be penalized with "non-accreditation" and hence, will get somehow a negative image from the patients, even if those physicians have good professional record.
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I think this bill did not  become a law, thanks.  Last week, a discussion with some friends in facebook about "open sky" policy and airline reciprocity moved to a discussion on reciprocity in the practice by professionals from other countries. Here's our brief exchange on the subject:

Nonoy: When Filipino doctors, nurses, engineers are allowed to work as doctors, nurses and engineers in the US, UK, Canada, etc., those countries did not ask for "reciprocity", that American, British, Canadian, etc. doctors, nurses and engineers should also be able to work here. They are banned from practicing here, Constitutional ban.

Steve: Nonoy, thanks for raising the issue of the closed doors of the Philippines to any non-citizens receiving licenses to practice, although our citizens can and do freely practice in many other nations, as long as they pass the test and pay the licensing fee. I think registered dietitions (or nutritionists) are the only ones allowed reciprocity and that only with the US.

Nonoy: Discussion of reciprocity, I think an "innocent" but hypocritical concept. "I open thiis so long as you open that too." So if one or both won't open, or just open up a bit, then both parties or both governments will be closing opportunities for their people. It's good that the US, UK, etc. are more open minded with regards to mobility of people, they allow Fil doctors, nurses, engineers, dentists, etc. to practice in their countries, did not ask for reciprocity from some slightly xenophobic governments like the Philippines.

Steve: I don't know the policies of openness in licensed professions for Japan and Korea, but the US and UK certainly allow any competent person to practice, regardless of citizenship. Perhaps a case could be made for that infusion of talent and "mind-power" adding to the power of the economy?

Nonoy: I think even the leaders of the local professional organizations (PMA for physicians, PNA for nurses, UAP for architects, IBP for lawyers, etc.) who probably lobbied for that provision in the constitution to ban foreign professionals from practicing in the country know the arrogance and hypocrisy of their position. They did not even cite "reciprocity", they simply wanted an outright ban and prohibition of foreign professionals.

All economic growth of any country mainly comes from one important resource: people, their brains and muscle. That is why big population countries usually have large economies -- more entrepreneurs, more workers, more professionals, more consumers. But some small population countries have big economies too, because of the entry of more brains, including foreign brains and muscle, into their country. LIke HK, Sing, Netherlands, etc.
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I hope that should a constitutional change become a reality someday, not only the 60-40 restrictions on foreign equity be removed, ie, foreigners can own 100 percent equity in more sectors and industries in the country, but also the restrictions on the practice of foreign professionals here will also be lifted. Especially for health professionals like physicians, dentists, nurses, med techs, pharmacists, and so on.

See also:
Health Transparency 1: MeTA Forum January 2009, January 26, 2009
Health Transparency 2: CHAT Discussion and Debates, June 15, 2009
Health Transparency 3: MeTA Forum January 2010 (Prevention vs. Medication), January 27, 2010
Health Transparency 4: Drug Promotions and Government, September 03, 2010
Health Transparency 5: Forum on Good Governance in Health, March 08, 2012