Congressional hearing: Corruption allegations against PhilHealth

Congressional Hearing 5 August 2020
 
1) I do not agree with Cong. Defensor when he said that investing in an IT system while still using the All Case Rate (ACR) system will “computerize” corruption in PhilHealth. Regardless of the provider payment system, an IT system will actually help the Corporation and health care providers in 1) filing of claims, 2) reimbursement, 3) collection of data on health outcomes, and 4) analysis of data to inform policy.
 
The ACR system replaced the Fee-for-Service payment mechanism to simplify reimbursement processes and to promote efficiency in the delivery of quality care. The issue is not the ACR but how it was implemented. I believe a good IT system would have given us real-time data on the costs associated with specific bundles of care, utilization, and outcomes of care by collecting them in a systematic, secured way.
 
There is no perfect provider payment mechanism. Other countries utilize a mix of different PPMs. FYI the Philippines is now transitioning to global budget payments based on diagnosis-related groups. This policy was created by the same congressmen who approved the UHC bill.
 
2) COA suggests that PHIC will pay whichever is lower: case rate or actual hospital bill. The policy decision for this will serve as a precedent for prospective global budget payments. Quite dangerous, I must say.
 
In GBP, hospitals are provided a fixed reimbursement amount for a specific period rather fixed rates for individual services or bundles of services. This type of PPM provides hospitals the flexibility to allocate limited resources. In essence, it will help control costs.
 
There is a tendency for hospitals to under provide services. Hence, performance incentives should be linked to global budget payments. If PhilHealth will only be allowed to pay for actual charges, then it is precluded from providing prospective payments (GBP) which are allowed by the UHC law.
 
Finally, the Interim Reimbursement Fund (IRM) is also a form of prospective payment that is now being questioned by lawmakers. I do not understand their “anger” for “advance payment” when they were the same people who approved “prospective payment” under UHC?

On the corruption allegations against PhilHealth

I get our anger and frustration over the issue. But the claims forms (CF1, CF2, CF3, CF4) are not there to make it “easier” for PhilHealth to pursue corrupt practices. Actually, the forms are there to safeguard the interests of PhilHealth members by allowing the hospital to declare that the standards of care have been met. These forms are used so that hospitals can be reimbursed for the services they rendered to their patients.

I believe some PhilHealth employees are demoralized because of this issue. If the allegations are true, please spare other hardworking, honest employees who have given more than enough to improve health financing in the country.

Let us focus our frustration and disappointment on high ranking officials who swore to protect the interests of the people. PhilHealth, for the longest time, has not kept its promise of adequate financial risk protection. We still see patients who continuously suffer from huge out-of-pocket expenses that sometimes lead them to financial catastrophe.

This issue will have a great impact on our transition to DRG-based global budget payments. Ultimately, policy decisions made after this fiasco will determine how we will run the health financing system that will drive the universal health care we’ve always dreamed of.

We have the right to be angry, frustrated or disappointed. We have the right to demand for a better management. We have the right to demand accountability from those guilty of graft and corruption. And, yes, we have the right to a better health system that will ensure financial risk protection and achieve better health outcomes for all Filipinos.

Pandemic Financing: How the World is Funding the COVID-19 Response (Part 2)

What are the considerations in the provider payment mechanism?

How we raise money to pay for health care is an important issue. But equally important are the daunting tasks of organizing health service delivery, and compensating individuals and organizations that provide these services. To meet the increasing demand for health care services, health care workers need enough flexibility on methods of service delivery as well as in compensating for financial losses brought about by changing health care needs.

Service providers, especially those who are paid based on service outputs and volume (i.e. case-based payment or fee-for-service), will likely suffer from severe and sudden revenue losses due to the cancellation of elective and other non-urgent medical services.1,5 Moreover, some providers will be confronted with increased expenditure and costs (e.g. purchase of new equipment and supplies, higher staffing needs, etc.) which cannot be paid from their usual revenue sources.1,5 Thus, health and financing systems should quickly provide additional funds to hospitals and primary care facilities to compensate for both actual and anticipated revenue losses.

For health facilities, such as hospitals, who have been paid retrospectively based on fee-for-service or case-based payments, there is a call for a shift to other modes of provider payment.1 It has been suggested that the problem of maintaining provider revenue to prevent bankruptcy can be averted by front-loading budgets or capitation. In such a way, provider payment that would otherwise come through retrospective reimbursement of insurance claims will be paid in advance by providing a budget upfront based on historical utilization levels.1,5 In the Philippines, for example, Philhealth has released more than P43 billion to accredited hospitals to help them in the pandemic response of the country.16

Primary care, on the one hand, provides an essential foundation for the global response to the COVID-19 pandemic. It serves as a gatekeeper that can reduce the demand for hospital services. The main principles of primary care concerning the current pandemic include: (1) identify and manage potential cases as soon as possible, (2) avert the risk of transmission to contacts and health care workers, (3) maintain delivery of essential health services, (4) enhance existing surveillance, and (5) strengthen risk communication and community management.17

Inevitably, as the number of COVID-19 cases increases, the demand for primary care services will also increase. Therefore, health authorities should recognize the need to take immediate action to support the management of COVID-19 cases at the primary care level. Similar to hospitals, this will entail strategies to increase surge capacity and maintain stocks of personal protective equipment and other essential supplies, among others.17 The success of these strategies will be contingent on the availability of funds to support them. As such, widening the fiscal space for primary care facilities should come hand in hand with improving the health financing system for hospitals. This will ensure timely measures to address the needs of vulnerable groups in communities, and that essential health services are maintained to reduce preventable deaths.

In light of the pandemic, primary care also calls for support in innovations in service delivery. These innovations, such as teleconsultation and outside hospital care, aim to minimize the risk of COVID-19 transmission and maintain the provision of essential health services at the primary care level.5 Financial incentives can support the attainment of these objectives. Some European countries have already introduced or amended provider payment mechanisms to remunerate new forms of service delivery.5

Additional funds may also be needed to incentivize essential staff for their dedication and hard work during the pandemic. Pay-for-performance mechanisms are being revisited to adjust performance targets and ensure quality care is provided and incentives are appropriately given to deserving service providers1. Finally, health professionals who will have reduced income due to postponed or canceled elective procedures should also be compensated. Although some revenue may be derived from the adoption of telemedicine in numerous aspects of primary care, many medical and surgical specialties will have to deal with a significant decline in revenue.

What are the implications to the patient payment system within countries?

Citizens should be able to understand the importance of timely diagnosis and treatment of COVID-19. Concerns about the affordability of health care should not be a factor in health-seeking decisions as it may delay people from seeking treatment or be prevented from obtaining the services they need.5,8 Out-of-pocket payments, user fees, and co-payments at the point of care for essential services have been constant financial barriers to accessing health services, and sometimes push people to financial hardship.2,5 It has been argued that co-payments and user fees for all patients, including for non-COVID-19 health services, should be suspended.2,5

When user fees have to be suspended, it must be communicated clearly to people that services are free at the point of care.2,5 Patient benefits should be clearly defined and included in risk communication strategies and public announcements. However, the mere statement of free services might not be enough, especially in countries where people face other barriers to access (e.g. transportation costs).8

Unemployed or self-employed people, and those working in the informal economy, may not be able to pay their insurance contributions. In turn, this may render them ineligible to access health care particularly in health systems where entitlements are linked to payment contributions. To address this, some countries have already extended benefit entitlements to ensure wider coverage.5 In the long run, however, countries that have suspended co-payments / user fees and expanded insurance coverage will need additional resources to compensate service providers for lost user fee revenues.

References:

  1. World Health Organization. How to purchase health services during a pandemic ? Purchasing priorities to support the. 2020;(April). https://www.uhc2030.org/blog-news-events/uhc2030-blog/how-to-purchase-health-services-during-a-pandemic-purchasing-priorities-to-support-the-covid-19-response-555353/.
  2. World Health Organization. Maintaining essential health services : operational guidance for the COVID-19 context. 2020;(June). https://www.who.int/publications/i/item/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak.
  3. Kurowski C, Evans D, Irwin A, Postolovska I. COVID-19 (coronavirus) and the future of health financing: from resilience to sustainability. Investing in Health. https://blogs.worldbank.org/health/covid-19-coronavirus-and-future-health-financing-resilience-sustainability. Published 2020. Accessed June 13, 2020.
  4. Development Aid. Financing of pandemic response: where does the money come from? https://www.developmentaid.org/#!/news-stream/post/62753/financing-of-pandemic-response-where-does-the-money-come-from. Published 2020. Accessed June 13, 2020.
  5. Thomson S, Habicht T, Evetovits T. Strengthening the health financing response to COVID-19 in Europe. 2020.
  6. Barroy H, Wang D, Pescetto C, Kutzin J. How to budget for COVID-19 response? 2020;(March):1-5. https://www.who.int/who-documents-detail/how-to-budget-for-covid-19-response.
  7. World Health Organization. Health systems governance and financing & COVID-19. https://www.who.int/teams/health-financing/covid-19. Published 2020. Accessed June 14, 2020.
  8. World Health Organization. Priorities for the Health Financing Response to COVID-19. DOI:10.1596/33738
  9. Glassman A, Datema B, McClelland A. Financing Outbreak Preparedness: Where Are We and What Next? Cent Glob Dev. 2018. https://www.cgdev.org/blog/financing-outbreak-preparedness-where-are-we-and-what-next.
  10. Cylus J. HOW MUCH ADDITIONAL MONEY ARE COUNTRIES ALLOCATING TO HEALTH FROM THEIR DOMESTIC RESOURCES? https://analysis.covid19healthsystem.org/index.php/2020/05/07/how-much-additional-money-are-countries-putting-towards-health/. Published 2020. Accessed June 18, 2020.
  11. Stone M, Saxena S. Special Series on Fiscal Policies to Respond to COVID-19 Preparing Public Financial Management Systems for Emergency Response Challenges 1. https://blog-pfm.imf.org/pfmblog/2020/03/preparing-public-financial-management-systems-to-meet-covid-19-challenges.html.
  12. World Health Organization. Joint External Evaluation of IHR Core Capacities of the Republic of the Philippines. Geneva, Switzerland; 2019. DOI:10.1142/9789812817945_0010
  13. Gupta S, Barroy H. The COVID-19 Crisis and Budgetary Space for Health in Developing Countries. https://blog-pfm.imf.org/pfmblog/2020/03/preparing-public-financial-management-systems-to-meet-covid-19-challenges.html. Published 2020. Accessed June 21, 2020.
  14. Barroy H. No calm after the storm: time to retool country PFM systems in the health sector. https://p4h.world/en/who-wb-no-calm-after-the-storm-time-to-retool-country-pfm-systems-in-health-sector. Published 2020. Accessed June 21, 2020.
  15. Verma A, Raj A. PFM Solutions in India to Combat the COVID-19 Pandemic.
  16. Philippines Health Insurance Corporation. OFFICIAL STATEMENT ON THE ALLEGED UNPAID CLAIMS TO PRIVATE HOSPITALS RAISED IN A RESOLUTION IN CONGRESS. https://www.philhealth.gov.ph/news/2020/rsltn_stmnt.php#gsc.tab=0. Published 2020. Accessed June 21, 2020.
  17. World Health Organization. Role of Primary Care in the COVID-19 Response.; 2020. https://apps.who.int/iris/bitstream/handle/10665/331921/Primary-care-COVID-19-eng.pdf?sequence=1&isAllowed=y. Accessed June 21, 2020

Pen Point 47

Duterte & his allies have mastered the art of deception and selective justice. Deception of people for the sake of the people is a contradiction in democracy. Indeed, politics is a dirty game. Remember that there are no permanent friends, or enemies, only permanent (sometimes selfish) interests.

Inaction is action. Our government is responsible both for the things they do and the things they don’t do, especially when they could choose otherwise. Not until the majority of us choose to side with true democracy, we will continue to fail as a society.

Haven’t you had enough?

Burned and scarred

WARNING: This post contains sensitive content which some people may find offensive or disturbing.

Many of us assume that pay and other rewards are all that we can expect to receive from our work. There is less emphasis on less-tangible but equally important benefits like trust, respect, civility, and the opportunity to make a positive change. This view of our work encourages behavior and attitude that lead to employees’ burn out. Thus, contributing to a workplace culture that harms people’s well-being and sense of self.

Over the past years, I’ve struggled with the unprecedented consequences of psychological harassment (also known as bullying). Truth be told, I may not be the only one experiencing this. There are many who might have been blinded to see this kind of harassment as simply ‘part of the job’ or an act of ’keeping the organization intact’. Many of whom would not even know that they, too, are victims.

Our culture and system both cultivated a workplace environment that is punitive, antagonistic, cynical, and perhaps self-serving. Some of you might agree that culture, much like a system, is one that is hard to break or change. It takes considerable effort and political will to accomplish this. However, it is my fervent prayer to see the day that workers get to enjoy working in a workplace that emphasizes the importance of openness, trust, transparency, respect, integrity, and accountability.

It has been months since I began thinking about my next big step. And, the recent burn accident that happened to me while on duty showered (figuratively) me with enough motivation to seek some enlightenment. For now, nothing is definite. But I am only sure of one thing: my conscience is clear. Nothing that I ever did or said intended harm to anyone. My views, opinions, and actions are all in accordance with my personal principles, the ethics of nursing, and the vision and mission of the organizations I am affiliated with.

It saddens me that my pure intention to help, no matter how it is expressed, is often dismissed with prejudice. These preconceived opinions, which I believe are not based on reason, have led to several instances of misunderstanding, manipulation, and most especially misinterpretation. The constant desire to prove one’s worth and sincere intentions has surprisingly taken a toll on me.

Today, I begin to seek ways on how to regain myself. I might be better off seeking fertile soil elsewhere to cultivate my skills and share the fruits I long to offer our society, rather than trying to build a garden in a barren desert. I wish to end the nights of loneliness and self-doubt. I pray that one day I will be able to regain or improve my confidence, well-being, self-worth, and sense of self. Tomorrow, we start the process by going back to the bedside and care for people who currently need us most.

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Disclaimer: Views and opinions in this post are my own. They do not reflect the official positions of the organizations I am currently affiliated with. If the shoe fits, wear it.

WE SHOULDN’T BE SILENCED. WE MUST BE HEARD.

WE SHOULDN’T BE SILENCED. WE MUST BE HEARD.

It is almost always difficult to make a decision. Probably, it is harder during a pandemic when you battle against time and limited resources. Not all administrators will make the right decisions. Not all employees will have the same opinion. What’s common, I suppose, is the collective vision of ending the pandemic at the soonest time possible.

Everyone is afraid, anxious, or worried about dealing with many uncertainties. As a result, everybody is doing all things they can to be saved. Obviously, some *subordinates*, as they call them, would want to be heard. Some people talk in small groups. Some in bigger groups. During a pandemic, it is natural for these people to begin to raise their concerns about how things are being handled. It is common for people to criticize decisions they think are doing more harm than good. It is common for people to propose solutions to problems that directly (or indirectly) affect them.

On the one hand, it should NOT be common and natural for people to blatantly silence critics who are airing valid concerns. Issues, concerns and criticisms are all part of leadership. Rather than thinking of them as bullets attacking or undermining the administration, it is more important for administrators to consider them as challenges. Rather than play the victim, administrators can own criticisms and convert them into opportunities.

Too many administrators get too defensive and choose to focus more on their reputation. They tend to impulsively react and dismiss legitimate issues and concerns, rather than objectively assessing or reevaluating the situation at hand. There have been times when administrators turn the criticism around the person speaking up. They end up chasing the ‘mastermind’ who can easily be blamed, rather than seeing it as an opportunity to learn from someone else. Yes, even from someone among the “subordinates”.

Criticisms are sometimes a clear reflection of poor judgment, but never of character or personality. TAKING CRITICISM IS A DIFFICULT THING. But criticism can always be considered a form of communication – an honest feedback on what transpired after a decision was made. Such feedback can make us stronger by allowing us to listen to honest views that tell us what can be done better. Moreover, TAKING CRITICISM IS UNCOMFORTABLE but it forces us to think about how we work and how we decide. Constructive criticism can guide us away from making poor judgment and subscribing to bad practices.

I believe one of the most important qualities of an administrator is being a good listener. And that applies more when one is being criticized. Don’t always shut them down. Turn up the volume, lend your ears, and listen to what is being said. Be the change agent people want you to be. Turn the negativity into an avenue that enables growth, maturity, and innovation. Turn words into action. Show that you can listen to feedback and at the same time get the job done. Together, let us change the workplace culture of blame. Let us heed the call to become more honest, transparent, and consistent.

Rather than flashing your palm at someone, open up your arms and say…
“I have thought about what you said and this is what I’m planning to do. What more do you think can we do?”

The frontline

As a nurse, waking up each day is a struggle knowing that there is a high risk for us to acquire the disease. However, we are constantly reminded of our duty to the people. That it is our duty and responsibility to help those in need, especially the poor, weak, and vulnerable.

Times like this make us realize that effective communication is key. Sadly, the field of health has failed to do it well in many instances. Today, more than ever, I fervently ask our leaders to first show TRANSPARENCY. Make things clear for us. Make us understand how things will be managed, coordinated, and disseminated. Make us feel that you are on top of this and that processes are as clear as they can be.

Second, I ask for CONSISTENCY. We are tired of hearing conflicting statements, especially those from the higher ranks. Such conflicting statements create confusion which in turn causes panic. Let there be a single message from a single source.

Finally, I ask for INTEGRITY. Let us not fool each other. Again, kabaro mo na. Sana hindi ka na isahan pa. Tayo-tayo dapat ang nagtutulungan. Hindi dapat nag-gugulangan. Let us be honest to each other so we can all work well together. After all, we all aim for one goal – the end of this crisis.

The coming weeks will show how resilient and responsive our health care system is. The circumstances will test how our current systems will adapt and change according to the pressing needs of the people. Our experiences during this pandemic will surely change how we will implement the UHC law in a bigger scale in the following years.

Please pray for everyone, especially those in the frontline. It is a scary, scary world and we have nobody to save us but ourselves. Ingat!

DISCLAIMER: There is no way this post pertains to a particular individual, hospital, or organization. Before you try to twist whatever I said in this post and send complaints, please clarify them first with me. Send me a message. It’s free.

Foreign ownership in the health care market

The proposed measure to allow foreign ownership of transportation and telecommunication services clearly sets a precedent for other public services in the Philippines, such as health care.

Opening the Philippine health care market to foreign ownership, obviously, has potential benefits including employment opportunities, better provision of health services, and health technology exchange. Foreign ownership of health facilities/service providers, however, has the potential to negatively affect the already struggling health care system of the country.

First, foreign investors may be enticed by the government to own hospitals and other health facilities (laboratories, ambulatory clinics, etc) in places where the government has failed or is yet to invest in. In this way, the government is lifting itself from the burden of expanding its public health services by allowing foreign investors to build and own these facilities. While this could be a win-win situation, poor regulation might undermine the primary intention of such set-up which is to improve access to health care services. In places where there is only one (monopoly) or few firms (oligopoly) providing health services, there is a potential for these firms to collude in order to maximize profits.

Second, foreign ownership has the potential to further promote a two-tiered health care system, separating the upper class from the low and middle classes. Having a two-tiered system means enabling price discrimination as an effective price-setting strategy. With price discrimination, some consumers will end up paying higher prices.

Unpaved road to UHC

Almost every day I see patients (or their relatives) looking for stretcher beds as there are no longer available beds in the emergency room. This scenario, I suppose, will persist even when hospital renovations are finished this year. While increasing the hospital’s bed capacity potentially decreases waiting time for patients, no amount of beds will ever suffice. The neverending influx of patients in the Philippine General Hospital is a result of the increasing demand for health care among poor Filipinos amidst rising health care costs. The same is true, or even worse, for other government hospitals.

PGH is a microcosm of the Philippine health care system. Our experiences in this hospital mirror big challenges that the country will continue to face while implementing the universal health care law. First, poor gatekeeping at the primary care levels will allow patients to seek care at higher level facilities even when lower level facilities are capable of handling their medical conditions. This, coupled with patients’ poor confidence of primary care health workers, encourage them to flock in tertiary level facilities which results in overcrowding.

Second, chronic lack of manpower and other resources delay necessary care. Patient waiting time is high for common radiologic procedures (e.g. x-ray, ultrasound) because there are only few machines available for hundreds of patients. Nurses, faced with high patient workload, leave out essential care elements to meet only the urgent physiologic needs of their patients. Our study on nursing care rationing in PGH showed that 45% of nurses kept a patient who rung for a nurse waiting longer than five minutes. More than half of respondents disagree that there are enough nurses to get the job done or to provide quality care. More than half of nurses also reported a physician did not come or took a long time to arrive after a call.

These are few of the challenges that patients and health care workers in PGH continue to face. While we strive to be a model of health care delivery, our current set up is far from what we all have dreamed of – a hospital that transforms lives through excellent care, education and research. I cannot imagine how other hospitals and health workers deal with poorer work conditions.

The road to UHC is quite long. PGH is a reflection of the government’s failure to adequately lay concrete interventions that will make our journey smooth. Gatekeeping at the primary care level and provision of adequate human resources for health are two key elements that will drive the realization of universal health care.

Top Nine Questions This 2019

It has been a great year. I cannot thank enough the people who have been part of this amazing 2019!

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In the past, I wrote top lessons I learned during the year. For this year, I will have to put them aside and share with you nine questions I had in 2019 that remain unanswered (or partially answered). I hope to find answers in the coming new year.

  1. Can the healthcare system achieve both equity and efficiency at the same time? Or are the two concepts contradictory in healthcare? Should one be achieved before the other?
  2. How can we make the procurement process be more flexible and less corrupt while being strict on the quality of materials procured?
  3. What incentives could eventually reconcile self-interest and social interest?
  4. Should state-funded health care be rationed? How should the government ration health care to meet the current demand? How does rationing of care contribute to universal health care?
  5. Does the current national social health insurance program increase or decrease the efficiency of the use of scarce resources?  Is ‘access’ rather than ‘utilization’ of health services a better measure of equity in health care?
  6. Do patients’ preferences affect the supply of health care services? Or are variations in the supply of health care services in various settings simply a response to high levels of patient demand? If not, how much do patients’ preferences contribute to utilization of health care services?
  7. How do we go about the Filipino culture of putting too much trust on one’s doctor to the extent that we lose exercising our right to participate in decision-making?
  8. Do we cast our nurses as “global goods” rather than “domestic providers” of health care, implicating them as sources of remittance income rather than for their potential contributions to the local health system? Is this kind of trade (trade in health services/providers) not only motivated by the desire for revenue, but also by the desire to cope with overproduction and lack of opportunities for nurses in the Philippines?
  9. Do people’s preferences and tastes change in situations where there are very few choices? Or do they develop an acquired taste/preference because of limitations posed by societal inequities?