PhilHealth probes steep rise in cataract surgeries



MANILA, Philippines—Health officials are investigating how cataract operations have become the highest paid-for service under the Philippine Health Insurance Corp. (PhilHealth), the national health insurance program.

Health Secretary Enrique Ona said he ordered the investigation after one ophthalmologist was able to obtain P28 million from PhilHealth for cataract surgeries that he performed in just one year.

“Since PhilHealth began supporting cataract operations—it gives P18,000 per eye operation—within a period of something like two years, cataract operations (have become) the highest paid-for service of PhilHealth,” he told a press briefing on Friday.

According to Ona, the ophthalmologist who became the highest paid cataract surgeon by PhilHealth last year “had very little practice two or three years before.”

He said the Department of Health was not investigating particular ophthalmologists but was looking into how these cataract surgeries had become the leading type of operation under PhilHealth.

Not a racket

“Now let us not say that it is all (a) racket. Maybe there are really that many unmet needs of our people, especially senior citizens who have cataracts … but that has to be proven,” Ona said.

He said old people usually developed cataracts “but the question is whether they should have surgery.”

“We want to determine if the patients really needed these surgeries. These operations became the no. 1 paid service by PhilHealth,” Ona said.

“I’m not saying that the doctor was guilty. We want to look into how these (surgeries) grew in number so fast,” he added.

University of the Philippines-Manila Chancellor Manuel Agulto said the eye doctors involved should have been investigated “from the start.”

“I want to tell you that those who do these are just a minority. I am the ethics committee chair of the Philippine Board of Ophthalmology and I’m very angry and very emotional about this issue,” Agulto said.

2 million with cataracts

According to Agulto, two percent of the Philippine population, or around two million Filipinos, have cataract problems but not all of them require surgery.

“Majority of ethical ophthalmologists out there in the field are not doing this. It’s the unethical ones who are trying to make money out of the misery of our countrymen,” he said.

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  • bogli_anakdami

    dang!… punta ako dito kay flip doctor/quackdoc for a consultation… he recommended operation for anything that ailed me…  o-PERA pala ang ibig sabihin ni quackdoc…

    also, noticed that “high UTI” was the common diagnosis for patients… WATDAPAK!!!!???  UTI is urinary tract infection???… patients were coming in with cold/flu symptoms…the prescription meds don’t even cure infection…

    kc, mga flip gung gongs don’t know anything about diseases… and, would believe anything the quackdoc tell them…

    hay naku… putang inang mga flipdocs talaga… dapat eh mag-abroad na lang at doon maghugas ng porener’s pwets…

    • Eric

      You remind me of a Siamese fighting fish fighting his own reflection.

      • bogli_anakdami

        and, you validated yourself as a typical flip gung gong who believe anything a flip magnanakaws have to say and do…

  • speedstream2

    All things considered, including use of the latest techniques as well as the physical and mental demand on a practitioner, how many cataract operations can be reasonably undertaken by a qualified doctor in a year’s time? Can all his patients be accounted for, with some random checking done to find out the post-operation state of their eyes? Shouldn’t the Philhealth have some sort of early warning system to alert it to an unusual spike in Philhealth-covered procedures?  Btw, is the ophthalmologist income tax copacetic?

  • Rovingmoron

    Now, the Bureau of Internal Revenue has to investigate if that eye doctor has paid his taxes correctly.

    • RNKR2005

      Payments made by PhilHealth to doctors are automatically tax deducted.

  • Father Aloy

    2 words – ghost surgery

  • novaliches

    sipag ng doktor na ito, jingle lang ang pahinga. bakit ka pa mag-aabroad kung P28M kayang kitain sa pinas.

  • genesis

    maybe it could also be the previous policy guiding cataract operations in the country. when i was operated for cataract in both eyes, i remembered my doctor commented that i was lucky because i was not covered with the philhealth policy to observe at least three to four months as the period in between each operation.. that said, within the span of three weeks, my both eyes were operated and the cataract  removed. 

  • tarikan

    Easy to trace the paper trail. Investigators should concentrate on looking for the addresses of the patients (on file with the hospital) and interviewing them. Baka may mga address sa kangkungan haha.

  • unokritiko

    onang ana dito ay bakit nagiingay itong si ona tungkol sa  philhealth  para sa cataract operation!!
    siguro hindi ito naambunan ng philhealth higher official.
    In fact this department of Health were ona is boss should give some remedy how to prevent cataracts specially for elderly people. The DOH is inutil and does not even give any suggestions regarding this matter. and when the budget flows into this in big amount they began to blah blah.

    If there is an anomally about cataract operation using philhealth card, then it should not be the doctor income that will be scrutinize but rather the philhealth official giving the budget to this doctor should be investigate first. then doctor  will be the second culprit in this issue.
    Sure there is connivance between this two person, itaga mo pa sa bato!!!!!

    • RNKR2005

      Obviously hindi ka familiar sa cataracts. There’s no way to prevent it, unless you can prevent someone from getting old. Or take out a person’s natural lens from his/her eyes even before it develops cataract.
      PhilHealth is a government owned financial institution providing assistance to the medical needs of its members. As head of PhilHealth, it is Secretary Ona’s responsibility to BALANCE the financial viability of PhilHealth with the needs of its contributing members.  If there is any illegal activity draining its funds, he is bound to investigate it like any other competent manager.
      There is no budget allocated to each doctor.  Each patient undergoes/receives medical treatment, and is supposed to be given a deduction on his hospital bills if he is a valid PhilHealth member. The medical institution files the necessary documents to be able to request for for a reimbursement of the deduction given the patient.  A group of people from different PhilHealth offices receive the documents from the medical institution and decide whether to release the reimbursement to the medical institution or not. By this setup alone, unlikely that a single PhilHealth staff is involved with a scam.
      If this particular ophthalmologist received P 28 million in a year, he should’ve performed 5,000 cataract surgeries in 365 days or 14 cataract surgeries every day without Sunday breaks. Assuming he is a fast surgeon and he can do every surgery in less than 30 minutes, it would take him 7 hours in the operating room every day.  Were will he get the time to screen patients that he would eventually operate on, much less have the time to do postoperative checkups?

      • unokritiko

         just use your “sentido common” my friend, If this doctor earns 28m in a year and your investigation is first focused on this guy!!??sure it will fail!! in the first place were did this 28m came from? Philhealth, right!!!
        So in this case the philhealth official should be investigated first rather than Zeroing in on the doctor. The opposite of this action  is illogical and only idiot will do it like the DOH Personnel.
        now once the documents is in place and proper thats the time the DOH should invite this quack doctor of ophthalmologist.

      • Steve

        prevention of cataracts haha! thumbs down dude, kakahiya ka. 

      • RNKR2005

        Preventing cataracts is like preventing white hair. By preventing old age, or removing the very object where white hair and cataracts develop

      • unokritiko

        Use your advance knowledge my friend, think you dont know yet about stem cell treatment.
        and its major cure is how people become younger.
        theres a lot of other positive effects and its one of it.
        you really got a tiny brain as compared to mine together with this quack doctor below this comment.

      • RNKR2005

        Stem cell treatment? Hahahahahahahahahahaha. You are entirely basing all you’re assumptions on hearsay and exaggerated claims. Do you even know how it works? Have you even heard of DOH’s caution about stem cell treatment? Or that U.S. FDA hasn’t approved stem cell treatment in many of it’s claimed applications? Or that stem cell treatment is in its earliest stages of experimentation in cataract treatment?
        You’re totallly hilarious. If there is a stem cell treatment for cataract, for sure it would be big news in annual medical conferences of ophthalmologists. Can you post a link to a research study claiming stem cell therapy can treat cataracts in humans?  Facts dude, not news bits from biased entities. Stem cell treatment is most commonly used by dermatologists to make you LOOK younger. I know this because my sister-in-law gives us stem cell skin treatment. But you injecting stem cell treatment to make poeple become younger is the equivalent of kuwentong barbero in this discussion. Do you even realize that LOOKING younger is not the same as BECOMING younger?

        BTW, what are you’re qualifications in claiming that you have a bigger brain than mine or Steve’s? What medical school did you went to, what residency training you underwent and how many years of medical practice have you accumulated? Do you even know what DPBO really means? I bet you don’t know what it is and that you will even concoct some stupid meaning…

      • RNKR2005

        Stem cell treatment is very expensive when it is being given free in several clinical trials in the U.S. Millions are being charged to patients for unproven stem cell treatments all over the world versus free in U.S. laboratory trials. Hmmm. One person here is quick to accuse people without solid proof whereas there is factual reports of overcharging patients clinging on to hope for alternative treatments to serios diseases…

      • RNKR2005

        “Sentido common”? Are you even familiar with the setup between doctors, hospitals and PhilHealth to decide what is “sentido common” or not? I’m in the same line of work as this doctor, and his activities whether legal or not affects many in our community. Before anybody accuse me of being in the same boat, I take pride in protecting the integrity of my reputation by not participating in unethical/illegal cataract schemes.
        You are 100% wrong in assuming that there is a Philhealth official giving a budget to the reported doctor because each doctor does not have corresponding allocated budgets within PhilHealth. If a doctor treats an hospitalized patient or performs surgery on a patient with valid PhilHealth membership, PhilHealth sends payment for deductions given to PHIC card holding patients.Whether a single PhilHealth official is assigned to a certain specific doctor I’m not sure, but if that is the case it would be a very inefficient setup since there would be massive problems because of the number of doctors multiplied by the number of hospitals multiplied by the number of patients. 
        To be all theoretical about it, it is possible for an ophthalmologist to be able to perform 5,000 cataract surgeries in a month. He just have to forego holding clinics.  Other doctors/personnel may identify patients who would need surgery, while eye doctors may perform the postoperative follow-ups. Some may see this as improper and unethical, but it is not automatically illegal.  That’s why PhilHealth has difficulty cracking down on this types of doctors because a SOME of them are not breaking any law. 
        If PhilHealth focuses it’s investigation on a certain PhilHealth official, it won’t matter much since the practice is happening in many parts of the country especially in Visayas and Mindanao. There are loopholes in the system that PhilHealth has been trying to change for several years. 
        Your “sentido common” is assuming that a PhilHealth official is responsible for one doctor receiving P 28M. I understand your pessimistic, rather simplistic point of view from someone learning about it from the news reports. But for someone like me who has known about it for years and is remotely familiar of the system between patients, doctors, hospitals and PhilHealth, it is a system that can be taken advantage of by people performing practices both legal/illegal. How I wish that these runaway doctors can be charged with some violation, but even the Philippine Academy of Ophthalmology, Philippine Medical Association, Philippine Regulatory Commission and PhilHealth has been helpless to discourage these practices for various reasons.
        Changing the system of how PhilHealth evaluates and pays for doctors and hospitals is much easier than investigating doctors and PhilHealth staff

      • unokritiko

        Again, doc youre not using your commone sense in this issue.Assigning one philhealth official for every doctor is absurd reasoning!!!
        Philhealth people gives authority to deduct from the govt budget allocated for such operation. and assumes that this shenanigans from philhealth will not be checked by DOH. This every deduction from philhealth is scattered all throughout the archipelago. You can not noticed it but when the DOH make summary of budget deduction sure they have the opportunity to be cautioned by this anomalous transaction. Seem to me you sided with philhealth shenanigans, and this shenanigans operates illegally using the budget of this PHILhealth to accumulate money into their pockets. Of course there is connivance of doctors concerned or they just fake the doctors signature. This is how they enriched themselve using the govt money!!
        Youre seems right to say one philhealth official but you are dead wrong about it. They worked in group my dear doctor.!!!

      • RNKR2005

        Again you are making assumptions that highlight your ignorance.   The money that PhilHealth uses is not from the budget of national government but from the collective amount amassed from the monthly premiums paid by millions of people and private companies. This money is invested in various ways. Do you even know that PhilHealth is a GOCC (government owned and controlled corporation)? Just go to PhilHealth’s website, somewhere there it says “Philippine Health Insurance CORPORATION”. It operates similar to any private health insurance corporation, except that it’s officials are appointed by the government.  PhilHealth has its own money that is totally autonomous from the national budget.  The national government can get money from PhilHealth if approved by the latter’s board of directors (like what happened in GMA’s administration), but not the other way.  PhilHealth’s budget is not controlled by DOH. They can do whatever they want, but at the end of the day they are still reviewed by the Commission of Audit.

        BTW, it was you’re allegation that there is a PhilHealth official involved in releasing P28M to a particular doctor. Review your first post 3 days ago, second paragraph. It is only in your last post that you alleged that there is a group behind it.

        If you didn’t get my point before, I was trying to enlighten you on the relationship between PhilHealth, doctors and hospitals. I’m not siding with anybody. Eventhough P28 million is a eye opening figure for a single person to receive, I can think of several scenarios that could explain for this without breaking any law. If PhilHealth cannot find any illegal activity by the ophthalmologist, what are you gonna charge the PhilHealth official/s with? As long as the documentations from the doctor and hospital are complete, it is PhilHealth’s responsibility to pay the doctor and hospital. Can you enlighten me what law those PhilHealth official/s are violating if?

        Least of all I’m not siding with these “shenanigans”? You know why? Because these “shenanigans” are negatively affecting my work. But I will not make irresponsible comments and make conspiracy theories without proof like you are obviously doing. Don’t get me wrong, if you turn out to be correct that there is a shadow group within PhilHealth responsible for these “shenanigans”, I’ll be very happy because it will mean more PhilHealth funds available for honest working doctors. THOUSANDS of eye doctors have been complaining of these “shenanigans” for the SEVERAL YEARS without anybody going to jail because it is hard to prove any illegal activity inside and outside of PhilHealth. You are just one person who’s been aware of this issue for one week, versus thousands of doctors facing this problem for almost a decade. Do you think you’re conspiracy hasn’t been looked into yet by doctors who treat some of the most prominent politicians on both sides of the political fence?

        Again I emphasize, what law is being violated that you’re PhilHealth conspiracy doing?  As long as the documents are COMPLETE and TRUTHFUL, PhilHealth is duty bound to pay doctors/hospitals. If you can enumerate one, then you will be a big help to ophthalmologists nationwide…

      • unokritiko

        Have you encountered before, Philhealth got an anomalous release of funds by the group of people working with philihealth and its around 40M. Then if you dont knew this news you have a capot brain as it is shown in what you wrote above.
        This 28M is again an anomalous transaction to begin with, the doctor concerned was involved in these mess as maybe youre the one involved here. Why ? No matter what documentation you submit or the particular clinic, still there is an anomally as this can not be done by one quack  doctor of ophthalmologist like you.
        Violation with proper documentation!!!!
        common my dear quack doctor! Even if the documents are legal as you’re insinuating here, still P28M by one doctor income is very obvious to be doubted!!
        It just came across my mind that you are always in defensive move about philhealth,a nd you dont even knew the anomaly that went into this office, yet you know about all the transaction being done by this office.
        it is evident enough that you are involved in this mess. I send some part of this to the NBI for their scrutiny!! dont be alarmed!!!

      • RNKR2005

        Can you enlighten me as to the details of that P 40 million anomaly? If I’m not mistaken, that money was released by the board of directors for an anomaloes expenditure.  In cases of reimbursement to doctors/hospitals, PhilHealth supposedly sends payment every week, with amounts corresponding to the deductions given to patients.  Just because there are numerous anomalies in PhilHealth before (and probably in the present) does not AUTOMATICALLY make this P 28 million income of a single doctor a shady deal.  As I said before, AS FAR AS THE DOCUMENTS RECEIVED BY PHILHEALTH ARE COMPLETE AND TRUTHFUL, it is PhilHealth’s responsibility to pay for it.  I know it sounds ludicruous for a single doctor to amass that amount, but I suggest you visit some of the top hospitals in India and you can see that 20 cataract surgeries a day is not uncommon. (Some of my colleagues describe Indian operating rooms as something like assembly lines when they do cataract surgeries because they’re so fast that they can do several patients in rapid succession). So THEORETICALLY, an eye doctor can do P 28 million worth of cataract surgeries if he/she devotes all his time to surgeries and not perform clinical work.  
        You are immediately assuming there is something fishy with the documents PhilHealth received and I understand your skepticism because that is my same reaction initially. But a part of me still wants to give the BENEFIT OF THE DOUBT as long as no violation has been proven inside and outside of PhilHealth.
        You say that I am insinuating that the documents are legal? YOU ARE WRONG. 90% of me agree with you that something is fishy/manufactured/falsified, but a small part of me knows that it is still THEORETICALLY/MATHEMATICALLY POSSIBLE to do that many surgeries a year. You undoubtedly do not share by optimism which you are free to do.

        You assume that I am defending PhilHealth? No way in hell!!! They still haven’t paid for 50% of how much I should be receiving from PhilHealth, which is around 1% of what this reported ophthalmologist is receiving.  Put it this way, if all the anomalies are divulged and all scoundrels kick out, there might be a chance that I will get my hard earned money back.

        You want to send this discussion to NBI? GO AHEAD!!!!!! That will be a big favor to me.  With the proper press exposure, PhilHealth may see my predicament and get wind of what they owe me and eventually pay me. And while you are there, submit to the NBI your awesome expose on how some PhilHealth officials connived with this reported ophthalmologist. I’m sure they will be amused with your voluminous amount of proof which you are not sharing here. SINONG TINAKOT MO SA HAMONG MONG MAGSUSUMBONG KA SA NBI? Tingnan natin kong sino sa atin ang pagtatawanan. Meron QC congresswoman na tameme sa akin nung pinagtaasan ko siya ng boses over the phone when she wanted me to give preferential treatment to her constituent over other patients, you think I will be scared of a nobody like you?

        BTW, you still haven’t answered my question? Assuming (if you know what ASSUMING is) that documents sent by doctors/hospitals are COMPLETE and TRUTHFUL, what law are those people inside PhilHealth violating? I’m sure you can’t answer one simple question. That’s all I want to know, the law that PhilHealth shouldn’t pay a doctor that has PROPERLY TREATED A PATIENT AND SUBMITTED THE CORRESPONDING DOCUMENTS.

        If you don’t get it by now, I am taking the high road by not assuming in this discussion that there’s hanky panky schemes everytime big money is involved. I am not saying that everybody is innocent. What I think should be done is investigate the paper trail. Wherever the faulty paper trail falls, whether it is on the side of the doctor, hospital or PhilHealth, then apply the proper justice. But for the sake of this discussion, I am explaining that there is VERY SMALL CHANCE that nothing is irregular. Emphasis on very small chance. Whatever the case, PhilHealth should still review it’s policies on reimbursing doctors/hospitals. It is very unfair that one doctor gets P 28 million while they can’t pay half of what they owe me which is a very small in comparison.
        You can say anything you want, just take away from this that I’m not defending PhilHealth and my discussions are purely theoretical and based on assumptions of regularity which is the status quo for all signed documents.

        Also, do you always belittle those who do not go along with your point of view? Good luck with your life. Belittling others is a sure sign of how small you really are. I’m sure somebody else reading this would say bakit pa ako pumapatol sa isang tulad mo…

        Hahahahahahahahaha. Hindi ko pa rin makalimutan hirit mo about stem cell treatment. Mas bilib ka pa doon kesa sa experts sa International Society for Stem Cell Research

      • RNKR2005

        PS Just to correct a few things said earlier:
        1. There’s no way to prevent cataracts. Anybody old enough can get it. It’s a fact of life, some get it at their 50s, some get in their 90s, some will die before developing one.  If nobody dies and continue to grow older, everybody will get a cataract
        2. As a GOCC, PhilHealth’s money is not from the national budget. Congress/Senate can investigate, but it can not legislate where PhilHealth’s funds are allocated like what is done with the national budget

  • RNKR2005

    There are several unethical schemes that could be the reason for the high number of cataract surgeries. Sweepers, ghost surgeries, falsification of documents, etc…

    There is only a very small number of ophthalmologists that are involved with these questionable practices.  Unfortunately, the damage they are doing is so big that it is affecting the overwhelming majority of eye doctors…

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