From PhilHealth to FailHealth?

The Philippine Health Insurance Corporation (PhilHealth), a government corporation established in 1995, has the mandate under the recently enacted Universal Health Care Act, to adopt a “health care model that provides all Filipinos access to a comprehensive set of quality and cost-effective, promotive, preventive, curative, rehabilitative and palliative health services without causing financial hardship, and prioritizes the needs of the population who cannot afford such services”.

It is the biggest health insurer in the country as it assumed coverage for government employees from the Government Service Insurance System (GSIS), private sector employees from the Social Security System (SSS), and Overseas Filipino Workers from the Overseas Workers Welfare Administration (OWWA).

At present, PhilHealth also provides medical care to indigents in partnership with local government units, the self-employed, senior citizens, kasambahays, professional practitioners, Filipinos living abroad and with dual citizenship, Persons with Disability (PWDs), and practically all Filipinos at least 21 years of age. With the magnitude of direct and indirect contributors plus the subsidy from the government, one thing is certain – there is a lot of money in PhilHealth.

But sadly, according to a resigned PhilHealth official, there is also a “mafia” of executive committee members, and corruption to the tune of at least P15 billion. So, what else is new? There are allegations of questionable fund disbursement, overpriced information and communications technology purchases, excessive payments to favored hospitals and health care facilities, fraudulent schemes in the implementation of the case rate system, and irregularities in the Interim Reimbursement Mechanism (IRM).

It is noted that on March 20, 2020, PhilHealth issued its Circular No. 2020-0007 providing guidelines on the provision of special privileges to those affected by a “fortuitous event”. This allowed the IRM, which is defined as “a special privilege for the provision of substantial aid to an eligible Health Care Institution (HCI) directly hit by a fortuitous event with clear and apparent intent to continuously operate or rebuild the HCI in order to provide continuous healthcare services to adversely affected Filipinos”. This extraordinary “reimbursement” mechanism is an advance payment made to qualified HCIs based on historical data. In the past, this IRM was implemented to address the difficulties brought about by typhoons Yolanda and Ondoy, the Marawi incident, and the Taal eruption. While the apparent fortuitous event affecting HCIs on March 2020 is the COVID-19 pandemic, Circular 2020-0007 has no specific mention of this disease. Was it by design to include as beneficiaries all HCIs even if they are not at all involved in the fight against COVID-19?

There are reports about dialysis and maternity centers and even small infirmaries receiving large amounts from the IRM. It is alarming to hear allegations that notwithstanding the outlined procedure to avail of the benefit under the guidelines, HCIs, including those catering only to non-COVID-19 cases were already pre-selected to receive IRM payments. Worse, no specific liquidation processes were allegedly required at the time of the release of the funds.Issues of fraudulent PhilHealth claims made by doctors in conspiracy with patients, hospitals, and maybe PhilHealth officials too, hounded the agency for a very long time. With these criminal conspiracies, some neurologists and ophthalmologists allegedly made a lot of money from PhilHealth for simple procedures done in private clinics or even barangays outside of accredited facilities. Although several cases have been filed against these perpetrators, the large-scale criminals are still on the loose. My alikbabok tells me that they have very strong connections up there. Just check out the city that received the highest IRM shares. Then make your own conclusions.

I think the Senate did right in terminating its investigation, which ended up with hanging allegations and mere denials, so that the Office of the Ombudsman or the Department of Justice could proceed with dispatch in the conduct of the required investigation for the criminal prosecution of officials responsible for the alleged anomalies and the exoneration of the innocent ones. This will surely be a tough job for the DOJ and Office of the Ombudsman. Careful! Lest you pick on an anointed one.

Last week a bill was filed in Congress to grant the President the power to overhaul and even privatize PhilHealth. I can only surmise that this proposal was made from sheer frustration and disgust brought about by the corruption allegations. But is this the best option? From where I sit, public health, just like national defense, is so essential that no less than the State should take direct control and supervision of its promotion.

While privatization of PhilHealth may appear to be a viable option, we should consider that the infusion of private capital into the system is principally motivated by the desire to earn profit and never to render some public service. We should learn from the lessons of the past.

At present, the cost of private health insurance services cannot be afforded even by our middle- income group, not to mention the several service coverage exclusions stipulated in private health plans. If PhilHealth will be privatized, the desire for profit of capitalist investors will ultimately defeat the Constitutional mandate “to make essential goods, health and other social services available to all the people at affordable cost.”

If the problem is corruption, the government should strictly implement its anti-graft and corruption laws and further strengthen PhilHealth processes to avoid corrupt practices. Privatization does not solve corruption because the private sector is not free from the evils of corruption. Worse, the cost of corruption in the private sector can be passed on to consumers in terms of higher prices. As it stands, the government has more laws and measures to address corruption than any private corporation.

PhilHealth must be insulated from politics so that PhilHealth cards must not be designed for election purposes and PhilHealth benefits will not be determined by the need to give political favors. There may be a need to review the composition of the PhilHealth Board of Directors. Was it not reported that there was a disagreement between PhilHealth management and the members of the Board from the private sector, on the acquisition of the overpriced communication equipment? These directors from the private sector are actually the expert panel members appointed under the law, who must (i) be of recognized probity and independence and must have distinguished themselves professionally in public, civic or academic service; and (ii) be in the active practice of their professions for at least seven (7) years, among other qualifications. It might be best to professionalize the composition of the Board and do away with lots of ex-officio members.

And what is a retired soldier doing in PhilHealth? The law says that “the Board cannot recommend a President and CEO of PhilHealth unless the member is a Filipino citizen and must have at least seven (7) years of experience in the field of public health, management, finance, and health economics or a combination of any of these expertise.” Does he have the technical competence to deal with an entirely new health system he had no knowledge or full understanding of? Sanamagan! Something isn’t right here.

If you read about PhilHealth’s history of anomalies and corruption in every administration, you will note the key players in the field (some of whom are in congress and the senate at present).  It’s like a merry-go-round fancy. So, let’s wait and see. What will the next move of the President be? What will the PhilHealth Board and the so-called mafia do?  How will Congress and the Senate resolve this deeply rooted and quite hardened issue? Abangan!