COMMENTARY: The PhilHealth conundrum

At the height of the 2019 inquiry into anomalies at Philippine Health Insurance Corp. (PhilHealth) by the Senate committee of the whole, a fellow physician showed me a PowerPoint presentation on a very disturbing pattern involving the state health insurer’s payment for claims of reimbursement for services rendered by health-care institutions (HCIs).

HCIs have long been sending their claims to PhilHealth through an information technology (IT) portal. It is also through this portal system that HCIs can check whether their claims are in process or have been returned for deficiencies, denied, or paid. A major problem apparently encountered by HCIs long before the COVID-19 pandemic struck is the inconsistency of the data on the payment of claims. Very often, the portal system would show that the claims had been paid even if the hospital had yet to receive the payment.

By simply checking the Bureau of Internal Revenue’s 2307 form, which states the actual amount received by an HCI from PhilHealth, the discrepancy can be verified. The simple check indeed showed this glaring discrepancy, and raised an equally glaring question: If the PhilHealth portal shows that the claims for reimbursements were paid, but the hospitals did not receive them, where did the money go?

I asked my friend if officials of the hospitals concerned would agree to testify at the Senate. Unfortunately, they were afraid to do so. I kept the presentation and discussed it with authorities who, I hoped, could do something about it. But as current events show, the problem was never addressed. And because the pandemic has pushed hospitals to the tipping point, many of their officials are now loudly talking about it.

Other pressing issues

It is by no means the only issue hounding PhilHealth.

The lack of coordination with the Philippine Statistics Authority (PSA) has caused the continuous payment of premiums for elderly deceased persons by the Department of Budget and Management (DBM). The amount is not small. The 2021 report of the Commission on Audit that studied data from only 1 percent of PhilHealth hospitals showed that 8,156 deceased elderly persons were still in the PhilHealth database. Extrapolate this, multiply by 100, and at P5,000 per year per senior, this translates to around P4.078 billion in premiums paid by the DBM for deceased persons. A lack of data has allowed certain dialysis centers in conspiracy with some crooked PhilHealth officers to keep claiming for services rendered to deceased persons. A lack of coordination with the Professional Regulation Commission (PRC) is among the reasons for the very poor premium collection from professionals and the self-employed. We physicians are a “captive” group of professionals, paying premiums three years in advance in order to be assured of continuous accreditation as health-care providers; while premiums from salaries of employed personnel are deducted monthly, the collection of PhilHealth premiums from professionals and self-employed persons is dismal. Reformists have long pushed memorandums of agreement with both the PSA and PRC, to no avail. Why PhilHealth is resisting such common-sense solutions is beyond comprehension.

Then there are premium payments that are recorded to have entered the PhilHealth treasury but actually did not. The 2019 Senate investigation briefly touched on a finding that premium funds had entered the bank accounts of PhilHealth employees, but it was not pursued.

Deadly problem

This is a serious and literally deadly problem that first became public in 2013, when over P100 million in PhilHealth premiums supposedly paid by a large reputable company through a large reputable bank was found to have never entered the PhilHealth treasury. An investigation ensued, and the bank teller involved and a PhilHealth employee were killed. The honest IT person who discovered the anomaly left PhilHealth soon after, but many of those reportedly involved in the scam remained.

Only one person was held accountable but was given a mere slap on the wrist and then allowed to leave the country.

The same modus was discovered recently, involving a large reputable shipping manpower company. An investigative report was submitted for the signature of the then PhilHealth president, and a copy was submitted to the Senate.

But the then PhilHealth president refused to sign the report, and rightly so. Its recommended punishment for the officials involved in a scam worth over P100 million was, again, a mere slap on the wrist.

Then there is the PhilHealth legal division that was given a grade of “0” (zero) by the Governance Commission for GOCCs because of its failure to resolve cases. PhilHealth is a quasi-judicial organization that serves as investigator, prosecutor, judge and executor of penalties for all irregularities involving its officials, be they simple administrative cases or multimillion-peso fraud cases. One need not be a lawyer to know why certain cases are at a standstill. Sacred cows etc.

Corruption, a porous, fragmented IT system that allows anomalies to thrive, an inefficient yet all-powerful legal division in which extortion can flourish, the lack of accountability of sacred cows, blatant pressure from powerful politicians who think of health as patronage and who view PhilHealth as their political tool rather than a means to serve all, incompetence and a lack of understanding of the nuances of social health insurance among many appointed persons—these are only some of the systemic problems hounding PhilHealth.

The situation has gotten worse, compelling many competent people to leave PhilHealth. Until the problems are addressed, the full implementation of universal health care (UHC) will remain a pipe dream.

Since 2015, I and many reformists in and out of PhilHealth have been like voices crying out in the wilderness. In the last of a three-part series on corruption in PhilHealth published in the Philippine Daily Inquirer in June 2019, I discussed some of these problems. Today we are faced with the true possibility of many private hospitals disengaging from PhilHealth in order to survive the nonpayment of their claims.

As I write this piece, a dialogue is ongoing between the two parties. But even if the threatened disengagement can be warded off for now, the solutions will only be like Band-Aid applied to a festering wound.

Nothing short of an overhaul of PhilHealth is necessary.

The original version of the UHC bill filed in the House of Representatives called for the abolition of PhilHealth and the creation of a Philippine Health Security Corp. It was deemed the best way to remove the undesirables in PhilHealth, keep the good ones, and start fresh. But by the time it was to be defended on the floor, this provision was removed.

UHC Act

The next administration must be prepared to address the problems besetting PhilHealth head-on and ensure that the wheels of justice will turn swiftly to resolve cases of graft and corruption filed with the Ombudsman and Sandiganbayan. Both the UHC Act and the PhilHealth Act have to be revisited. Should PhilHealth remain an attached agency of the Department of Health, or should it be transferred to the Department of Finance and the Insurance Commission?

Should PhilHealth’s IT system be audited independently and randomly twice a year to ensure transparency? Should its legal and premium collection divisions be outsourced so that it can concentrate on health packages and validation and payment of claims for reimbursement?

These are some of the questions the next administration will have to deal with quickly. The pandemic is still upon us. Stronger and more frequent typhoons brought about by climate change, many communicable ailments, and a growing incidence of lifestyle diseases will require an efficient health-care system, especially for the most vulnerable. We need UHC. But for it to happen, we need a good national health insurance system. Competence, integrity and a strong political will among our leaders are necessary to address the PhilHealth conundrum, for all our sakes.

—CONTRIBUTED

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Dr. Ma. Dominga “Minguita” Padilla is a coconvener of Doctors for Truth and Public Welfare, and founder of the Eye Bank Foundation. She served as head executive staff of PhilHealth from March 31, 2015, to June 30, 2016. She is a recipient of multiple awards for her work in prevention of blindness, community service and curbing insurance fraud. She is a senatorial candidate of Partido Reporma.