This is in response to the column article of Mr. Charlie V. Manalo published on March 11, 2019 entitled “Where have all the PhilHealth funds have gone?”
In 2018, we posted a record net income of P11.6 billion which is 4400 percent higher compared to 2017. Our premium collections reached P132 billion while our return on investments is at P6.7 billion.
Our restated 2017 financial statement shows that we posted P237 million in net income instead of P4.7-billion net loss as previously reported. This was after all remaining claims were submitted in early 2018 for reimbursement. We already communicated this matter to the Commission on Audit for validation and concurrence.
On benefit payouts for pneumonia
Pneumonia was identified as the fourth leading cause of death and second leading cause of morbidity in the Philippines. With the ballooning number of claims for pneumonia, PhilHealth instituted reforms which include a minimum of four days length of stay which was later lifted and replaced by a medical pre-payment review. Recently, the requirement to submit Claim Form 4 was instituted to help us assess the quality of care provided to our members.
On payments for cataract removals
We have pursued aggressive measures to ensure that our fund is protected against abuses. In 2015, we have authorized up to a maximum of 50 approved requests per ophthalmologist per month but not to exceed 10 scheduled surgeries per day. This is to ensure quality surgeries and to prevent fraud as well.
Since then, there has been a decrease of some 33 percent in the total number of cataract claims between 2016 and 2017.
As of February 2019, a total of 22 facilities and 14 health care professionals were charged in relation to fraudulent cataract claims.
On the alleged 10.6-billion fund diversion scandal
This was the subject of congressional inquiries. We inform the author that cases have already been filed before the Office of the Ombudsman against those allegedly involved and we defer this matter to appropriate authorities to once and for all settle this issue.
On case rate payments
The National Health Insurance Act of 2013 defines “case-based payment” as a payment method that reimburses health care institutions a predetermined FIXED rate for each treated case or disease. Section 34 of the law allows us to employ this system as a form of provider payment.
Case rate empowers PhilHealth members by making it known to them in advance how much they are entitled to in terms of benefits for a particular availment. Case rates also reduce discretion in adjudicating claims, and allow PhilHealth to effectively impose its No Balance Billing (NBB) policy for indigents, sponsored, and senior citizen members.
Likewise, international experience with this type of provider payment shows that it encourages efficiency in overall medical management of cases.
On instituting reforms and commissioning experts
We have been continuously instituting reforms over the years to improve our operational efficiency. Parallel to the introduction of enhanced benefit packages, we have also intensified our efforts to curb fraud and abusive practices of members, accredited health care providers, and even PhilHealth employees.
Through the years, PhilHealth has been and is continuously managed by capable leaders who possess expertise and mastery of the law, actuarial science, medicine, among others. Each President and CEO appointed at the helm has contributed in their own way to what PhilHealth is now. We also have financial, actuarial and management experts within our ranks and in the board who contribute to the effective management of the funds entrusted to us by our members. In previous years, PhilHealth even hired the services of fund managers but due to audit concerns, their services have been terminated.
I believe that more than expertise, what PhilHealth needs at its helm is someone with strong political will to see through the completion of all the reforms it has to undertake, and to be able to extract discipline, and to address all the challenges brought about by the different views of internal and external stakeholders.
We would like to assure our members that we remain focused on our mission to ensure quality health care for our members. We welcome feedback from members like you, so that together, we can work towards further improving the National Health Insurance Program for the next generations to come.
(Sgd.)SHIRLEY B. DOMINGO, M.D.
Vice President for Corporate Affairs Group
PhilHealth