Allow me first to greet one and all a very happy new year. I hope the long vacation has rejuvenated each one to work harder and help transform PHILHEALTH in becoming a game changer in the delivery of quality health care to all our members.
The New Year 2015 promises to be a good and hopeful year. With the coming Pope Francis visit (just barely three days away), we begin our own journey full of hope, prayer, and commitment to uplift and provide quality health care service for all Filipinos, especially the most deprived and disadvantaged.
In a month’s time, we likewise celebrate our 20th year as a Social health insurance agency of government. As we reflect upon our many achievements and challenges, likewise pause and ponder where we envision our journey will take us in the immediate, medium and long term.
May kasabihan tayo na ang tao na hindi marunong tumingin sa kanyang pinanggalingan ay hindi makakarating sa kanyang tinutunguhan.
We started the year 2014 implementing the “all case rates”. From what began as the case rate for the 23 top most medical and surgical cases, we now have a package rate for every conceivable condition. An app (locally developed) is now in our website whereby any person can simply type in the ICD-10 code or the medical condition and get an instant response on the amount of our case rate benefit. Where before our reimbursement varied depending on the kind and type of hospital as well as the subjective scrutiny of our own people, this time anyone may now know exactly one’s entitlement from PhilHealth, regardless of the level of hospital, whether public or private. Consequentially, “turnaround time” (TAT) has been reduced by more than twice its duration; and with the exception of but two regions, we have been able to pay our providers way below the 60 day deadline provided for by law. A patient member may now demand that the same be deducted from his billing.
Likewise, we have also gone full blast in demanding the “no balance billing” or “walang dagdag bayad” for those in the indigents, sponsored, OFW sectors when serviced in government hospitals. When we began to implement this, compliance was a wretched 7 %, now I understand is 40% in August last year. Much still needs to be done. Government has decided to invest in the poor, all of the poor. Thus, from P 5 Billion in 2012, by 2014 P35.3 Billion pesos were earmarked to cover the poor and so-called “near poor” totalling 14.7 million families or more than 45 million individuals, as listed in the NHTS of the DSWD. To ensure full coverage of all the poor, we complemented this policy with the “Point of Care Enrollment” where the hospital pays for the annual premium of a person, who neither being a member of PHIC nor otherwise listed in NHTS, has been evaluated to being a destitute. Through this mechanism, we have been able to enlist for last year alone, an additional hundred thousand indigents. It is our hope that the time will come when government facilities shall no longer look upon the poor as “charity” or dole-outs or made object of pity. Health is a right and not merely a privilege and PhilHealth is the mechanism where such right may be demanded. Thus there is no reason for any of those belonging to the disenfranchised sector to be deprived of basic and other health care service.
As a social health insurance agency, we have covered all kinds and forms of conditions, without exception, without bias, without disqualifications, and even with the existence of pre-existing conditions. We have also been improving our Z benefit packages. These are life threatening conditions that at times exhaust our very savings. From our humble beginning of four (4) of the most common catastrophic conditions; breast cancer for women, prostate cancer for men, leukemia for children and our most expensive package thus far at P 600,000 for a kidney transplant, we have now expanded into heart conditions. Last October, 2013, we introduced our first lower limb prostheses in Malacanang with our first beneficiary being a traffic investigator who developed foot gangrene and had below knee amputation. He was rehired as traffic investigator one month after he received his prosthesis. Then we provided for ‘selected orthopaedic implants’ as yet another innovation to respond to our member’s needs.
Since then we have introduced several more packages including the soon to be launched colon and rectal cancer package. A “Peritoneal Dialysis First” policy was likewise offered for those suffering from renal failure. This treatment promises to be cheaper, easier for patients as it is mainly a home based treatment, and safer.
Unfortunately, the availment of all these packages has not been as expected. Perhaps due to our condition that there be first a reference hospital which would then supervise those of others approved for accreditation, or because we have limited it only to public facilities, we may need to rethink and loosen up some of the requirements.
What is promising with these Z packages is that we are able to draw some lessons from our application of the principle of “co-pay”. Co-Pay is the other side of the coin of NBB whereby in addition to our reimbursement amount, the member is made to pay from out of his own pocket a certain amount which he nor she may know in advance. The amount of co-pay is the tricky part. It must not be huge which impoverishes our member; yet substantive enough in order to prevent bankruptcy or insolvency proceedings on the part of the provider. For the Z packages, we are testing a maximum ceiling of no more than double or a hundred per cent of our own package benefit but always subject to agreement between the service provider and our Corporation.
Despite the increased coverage and the many benefits we have been offering, out of pocket expense has been going up. From the latest national health accounts, almost 58 % has been attributed to out of pocket spending. This is unacceptable and we must think of ways and means to reduce this substantially. We have to seriously study the concept of “co-pay” to those other sectors who are not benefitting from our NBB policy. Just as we strive to take care of the poor, the middle class and even higher echelons of our society demand that we reduce their “out of pocket expenditure”. It is high time that those who actually remit to us bigger premiums from their salaries are made to benefit from the largesse of PhilHealth. The “co-pay” must be eventually extended to all the other sectors, particularly those found in the formal economy.
Let me now reiterate that our MEMBERS ARE OUR PRIMARY AND PRIORITY CONCERN. Ang ating pangunahing pinagkakaabalahan ay ang ating miyembro. But that is only half the equation. Together or just as important, with our principal members, are their DEPENDENTS. Just for emphasis, I repeat, inuulit ko. Mahalaga sa atin ang principal or primary member; but equally important are their dependents.
Unlike other insurance entities, whether public or private, the beneficiaries, dependents, or heirs merely inherit or assume the importance of being a member when the member is dead or incapacitated. Peculiar to us in PHILHEALTH, our members as well as our dependents enjoy the very same rights, privileges, and benefits.
Of course, there are nuances; example, the benefit limit for the principal member is 45 days whereas the sum total of the benefit limit for all the dependents is also 45. But this does not however detract from the concept that a Member and Dependent is at par or equal to the other. The sooner we ingrain this in our thinking, in the way we do business with our clients, in how we treat them, the better it will be to be of service to them.
Just who are our dependents? They consist of our spouse, and on this we emphasize the legal spouse. They include our parents who are sixty years of age and over; or if below 60 years, are suffering from some form of permanent disability and totally dependent on the member. Dependents are our children below twenty one years of age or if over 21 years, they are afflicted with some form of permanent disability and wholly dependent on the member.
Minor women, or those below twenty one, who either gets married or even if unmarried, bears a child, is called an emancipated minor and is to be treated as a primary member. They may be registered at the “point of care” or earlier when they avail of pre-natal tests. In this instance, let us take advantage of our rule prioritizing women to become principal members.
Foster children or adopted siblings are also possible but for them we ask for additional documents such as the court order formalizing the relationship or other proof of the same.
We never register grandchildren as dependents nor collateral relatives such as brothers and sisters, uncles and aunts. Our dependents are only those considered direct ascendants and descendants from the principal member and no further. With the exception of the spouse, dependency is dependent on the blood relationship. Thus, by way of illustration, if a husband is listed as the primary member and his wife as his dependent, the same man cannot enroll the parents of his spouse as his dependents because his relationship to them is only by affinity and not by blood. Lastly, common-law relationships. We are witnessing this type of an arrangement in current relationships. Our Civil Law has defined this to mean a couple who have cohabited with one another and living as husband and wife for at least five (5) years but without the formalities of civil or church rites. This is difficult to prove but not impossible. In this instance, we must require in addition to our PMRF form, barangay attestation of such relationship and other forms of proof such as picture, affidavits and the like.
Our business processes must conform to our members needs including easier registration, unnecessary documentary burden, better grievance processes through direct filing, and when appropriate, faster adjudication of their claims. It was a welcome relief when we removed tedious documentary requirements and are now more inclusive. Part of this reform is not to require submission of data or documentation that we already have within the Corporation, such as the Member Data Record (MDR). I know we have already improved in this regard with the introduction of PBEF from the HCI Portal; but just very recently, I could not understand why we required our members to shuttle from one office to another just to secure this document when its’ very content was already in our records. Part of our reform is to provide the service to them and not to suit what is convenient for us.
It made no sense why we were at times harder on individuals coming to the program and yet so liberal in allowing certain claims, no matter how questionable they may seem. It is my hope that we be guided by this simple truism; it is not our members we should be worried about; but rather those who have the resources and wherewithal to manipulate and use them for their own nefarious ends.
It also goes without saying that when dealing or talking to our actual and potential members, we treat them with the courtesy, respect and dignity they deserve; an attitude we ourselves would want to be treated when we deal and want something from another.
The new PHIC law, RA 10606, passed and signed into law in the latter part of 2013, mandates that all pregnant women, with or without prior premium contributions, are now covered by us. In our IRR, we have initially covered them under Section 39 b of our Implementing Rules and Regulations, whereby similar to Our “Point of Care”, the annual premium payment shall be paid to entitle them to immediate benefits. We have likewise removed our limit of four pregnancies and now cover any number regardless. Another far-reaching consequence to us is the enactment of the new senior citizens law which will surely change again the landscape we work on. While we maintain our “lifetime memberships” for those who reach the age of sixty years and have contributed 120 monthly premium payments or ten years, the new law now mandates full PHIC benefits for all those reaching the age of 60 years regardless of whether they are members or not.
With a looming 3 million additional seniors for 2015, it may have an effect on our actuarial reserves. Since the law provides that this subsidy be taken from the proceeds of the sin tax, we have released our circular which provides for this mechanism. We shall encourage seniors to register as principal members including those previously categorized as dependents.
The General Appropriations Act of 2015 likewise carries a special provision whereby we are mandated to cover barangay officials, tanods, and health workers who otherwise are not paid by salary. We would have to further clarify this matter with the DILG, DBM, and other agencies in order to fully carry out the intent.
When government decided to subsidize the above sectors, together with the poorest of the poor, it goes without saying that more information dissemination is required such as the ALAGA KA for the indigents, or utilizing various forms of mass media, or any other medium that tends to strengthen knowledge of our members and give meaning to their right to quality health care. Excluding the poor from the benefits of health financing is just as bad as making it available only on paper but do nothing to inform or empower them. The former is by direct commission while the latter is by form of omission or negligence. One is no better than the other and must be avoided.
We shall soon be rolling out our revitalized promotive and preventive care package called Tsekap. Realizing that prevention is better than cure, we shall be investing on this benefit knowing that the costs of future hospitalization or curative treatment should be greatly reduced. Aside from offering basic examinations, diagnostics, and information to maintain healthy lifestyles, we shall also be providing out-patient medicines for many conditions including the three most common non-communicable diseases afflicting Filipinos; these being diabetes, hypertension and dyslipidemia or cholesterol control. The inclusion of more out-patient medicines for common diseases will not only complete their treatment but will also address the common reason for out-of-pocket spending for many Filipinos. As approved by the Board, this shall be initially rolled out to the indigents but eventually offered to all other sectors, including those in the formal sector, who having paid the most premium amount must be equally protected from the same ravages of disease affecting all Filipinos.
Tsekap as a program and policy that must be given the highest priority for implementation as it is hoped that it would be a real game changer, transforming into reality “universal health care” for all.
Our relationship with the LGU’s has dramatically changed. From one concerned with their own sponsorship of their “poor”, this time around we need to engage them to first, register their concerned barangay officials including the barangay health workers or those not compensated thru regular salaries as members of the Corporation; second, we need to engage their local business offices in order to make arrangements whereby all those processed as businesses or those requiring business permits for whatever reason, that PHIC membership becomes a condition to securing their own local permits; third, in so far as expanding our own preventive and promotive care packages, we need to expand and deal with the rural health units, accredited drugstores, including our usual clientele, their hospitals and other accredited facilities.
Ensuring continued enrolment and coverage of each and every Filipino, we are likewise engaging other relevant government agencies including the private sector organizations. At its first instance, we are coming to terms with the Bureau of Fisheries and Aquatic Resources to collaborate enlisting all their relevant stakeholders in the fishing industry which they have computerized into a single data base. From the poorest of the poor or the ordinary fisher folk to the highest industry player and commercial fisherman, we have to internalize their 2 million strong data base to ours. Before all the brouhaha came about on the Bureau of Prisons or National Bilibid, its director wanted to partner with PhilHealth in providing health care to the inmates, guards and other personnel. We believe the loss of political and civil liberties does not justify their lack to quality health care which cannot be deprived or denied. Our own pilot project in Mindoro, SAGIP, have taught us on how best to enrol the indigenous peoples in the country which could conservatively total more than five million individuals. With the cooperation of the National Commission on Indigenous Peoples (NCIP), we hope to mainstream our brothers and sisters without the usual hardships resulting from their own cultural diversities. Additional but timely intervention with the DSWD should likewise put under our system minors, orphans, elderly and disabled persons who would either not fall under our definition or simply forgotten as part of our community. With this thrust, we hope to significantly increase our membership closer to that of making each and every Filipino a member. An arrangement with the NSO would likewise help us register our members from the moment of birth as recorded in the facility and submitted to the civil registry.
We need to re-think and focus on our core competencies. What are the two main functions where we should excel in?
Membership is of course critical. We are practically the only agency that is mandated to enroll the entire Filipino people, every single one of them. And because we pay for health services to be enjoyed by our members, claims processing is the other key function that we must do better. Enrolling the entire citizenry is a gargantuan task and no other agency could do it except PhilHealth. No one should be left behind.
P 37.3 Billion has been allotted by national government to cover the poor and certain segments of the population. While we constantly improve the listing of the NHTS and ridding it of the dead, duplicates and other defects; it is imperative to work on the formal sector, particularly the private sector. This is important because it is our main source of premium contributions and those in the formal sector must correctly contribute that which is due them. We cannot simply accept a number given to us by the employer. Mandating EPRS is critical but it must be applicable to all. We cannot simply accept the amount they remit to us and assume the same to be true. We also cannot do the work for them. Their system must be made to comply with ours and their genuine payrolls to be utilized as our primary document of the personnel. We cannot simply accept a listing from them, then such list encoded by our own people to our system, without knowing whether the list was accurate or not. You said previously that we did not have the power to inspect; now the new law grants us to. From our own records, I have noticed companies paying various amounts every month and yet we never questioned the same. Like a broken record, let me reiterate that it is our duty not only to list the employees of a company but their dependents as well are just as important.
On claims, it is important we are able to scrutinize such through improved audit, monitoring and evaluation mechanisms. With case rate payments, we know that we reimburse faster rather than the FFS when we scrutinized each and every service or input. This would have to be balanced with a robust monitoring and auditing mechanism concentrating on certain transactions that give us indicators or badges of fraud. Coupled with actual inspections and visits, we hope to minimize overutilization, upcoding or outright instances of fraud.
We need to come out with the “Charge to Future Claims” policy and implementing guidelines. This is critical as it will put on notice those concerned that much as we are able to grant incentives, we also have the capacity and will to sanction those that need to be properly dealt with. This may not only be in the form of revocations and suspensions that could prejudice the delivery of basic health services in that community; but one where it should hurt them most, their financial capacity. We must now leverage our power of the purse in order to compel adherence to our rules and policies and to ensure that transparency, honesty, and financial social health protection is sustained for our members.
To respond to the call of the COO for accountability, it goes without saying that we must adopt mechanisms and processes that compel us employees and officials of PhilHealth to remain honest and true to our sworn promise to be dedicated public servants. It is not by accident that we are referred to as servants and not public lords. Public service is a calling and commitment to our people and not to ourselves, nor our family, not even friends, nor any other parochial or vested interest. Competency and values formation should be institutionalized. We must be uncompromising and stern on those who commit graft and corrupt practices and reward, commend, and uplift the others who are exemplary in providing genuine service for others.
Further, we reiterate the programs which must be finished no later than the second quarter of this year; if not sooner. The enumeration does not reflect order of importance since all of the ensuing must and should be accomplished.
First, casualization of all our contractors and project based. This is in line with giving them the dignity and respect due them as well as acknowledging the years of public service. No longer should they be treated as ghosts and nobodies in our Corporation. We hope to be the first to remove this anomaly and hopefully followed by other government agencies as well.
Second, salary integration. All benefits and allowances shall, as far as practicable, be integrated into each of our basic salary, thus giving us certainty of compensation to rely upon and offering better protection when we retire or even for application of loans, housing and the like.
Third, our Provident Fund. A good mechanism whereby the Corporation invests the equivalent of 30% to the employees’ 5% to augment a fund whereby through the years, the same should work out for better outcome and benefits to the individual employee. On this score, the initial seed money of P 50 million pesos shall be granted to start up the Fund.
Fourth, during our meeting and audience with members of your union, we likewise promised that management would come up with a proposed separation package for those who may want earlier retirement and better than the usual benefits they are entitled to; and,
Fifth, the Development Academy of the Philippines has adequately consulted with the entire organization, including those in the regions, whereby we should be implementing a nationwide re-organization of sorts. Just to put everyone at ease, it is basically a structural re-organization whereby because of our new mandates, the organization has to constantly adopt to the new challenges. We again reiterate that no removals or terminations are being contemplated. Nor would there be demotions. Having said that, it should also be clear that this restructuring should also not be a venue for any promotions. While we are not declaring that all positions are vacant, the position that you currently hold is still your position, though nomenclature may change to certain items.
Just before the year ended, we were able to obtain our ISO certification 9001:2008 for the PhilHealth Central Office, PRO IV-A, and the LHIO Calamba. The challenge is now for the other regions to achieve the same certification this year.
In another landmark accomplishment, we not only have a Board approved Corporate Operating Budget (COB) for this year 2015 as early as November of last year but we also have an approved Annual Procurement Plan before this current year began. With this, we can no longer accept the excuse that the belated approval of the APP led to the delay in the procurement.
We have likewise conferred our corporate wide orientation on the new Strategic Performance Management System (SPMS) that would be in place this year. And what is significant is that both the 2015 COB and the SPMS are anchored on our corporate balanced scorecard.
We are rethinking as well our policies on our core functions and those which can be performed by others better.
Penultimate, we reiterate the policy that as a consequence of their arrogant actions and bullying tactics, the ban on Mainland China still holds. Thus, no approval for applications of leave of absence shall emanate from my office for the entire China except for Hong Kong and Macao, as earlier lifted already. This would likewise mean that we do not entertain any delegation, official or otherwise. emanating from that government. This would be lifted only upon their adherence to international law and putting a halt to all of their provocative, aggressive and illegal actions against the Philippines.
Bilang pangwakas, taos puso ko kayong binabati ng isang Manigong Bagong Taon. Umaasa rin tayo ng isang mapayapang na Pagdalo ng ating hinahangaan na Santo Papa. Sana’y gamitin natin yun pagkakataon na eto para magkaroon tayo ng panibagong at dalubhasang paninilbi sa ating mga miembro, Corporation, ang ating Pangulo, and Inang Bayan at huli man banggitin ay hindi naman nahuhuli, and ating Panginoon, kung saang lahat nagsimula, ay sa kanya rin magtatapos.
God Bless you all and Mabuhay po.
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