HMOs: Providing plans under threat of being sued violation of our right

Requiring private health maintenance organizations (HMOs) to provide healthcare packages for senior citizens under threat of being sued is a violation of their right as a corporate citizen, the Association of Health Maintenance Organizations of the Philippines Inc. (AHMOPI) has said in a statement.

AHMOPI issued the statement following the call of Pasig City Rep. Roman Romulo that the Insurance Commission should penalize the private HMOs for discriminating against the country’s more than six million senior citizens.

Romulo, who is running for the Senate, noted that HMOs refused to renew the coverage of planholders when they reach 60.

He said Section 11, Article 13 of the 1987 Constitution mandated the state to make essential healthcare services available to all, especially the elderly.

The lawmaker filed House Bill No. 6348, the proposed Anti-Healthcare Age Discrimination Act, which imposes administrative fines of up to P300,000 on HMOs that refuse to sign up individuals who are over 60 years old.

According to Carlos da Silva, AHMOPI executive director, they agree with Romulo that HMOs should not discriminate senior citizens.

However, he said “let it be the decision of the HMOs concerned to offer plans for senior citizens and if ever they do, at a price equitable to both parties.”

Da Silva explained that many factors were being taken by HMOs in pricing their products, such as the prevailing medical costs in the industry; attained age of an individual applicant or the median age for a corporate account; risk assumptions on existing health profile/s of the individual or group; occupational or environmental hazards of the applicants; industry classification they belong to; past history of program utilization (for renewing accounts); medical or lay underwriting results, if any; marketing and selling expenses, if any; competition in the marketplace; the company’s administrative loading; the many benefits of the program including latest modalities of treatment; tailor-fitted benefit inclusions per client requests; medical network including specialists; and point-of-service privileges, among others.

“All these are taken into consideration in order to price correctly the risks involved and the cost of doing business with a particular client,” Da Silva said as he admitted there were “very few HMOs who have taken the risk on geriatric care plans for senior citizens.”

This, he said, was “primarily on account of the fact that geriatric care encompasses a more holistic approach to cope with aging and its effects not to mention the onset of the inevitable failing of mental and physical health-health.”

He said some HMOs may not be prepared to undertake such risks.

“Just like any business organization, HMOs package their products and services according to their capacity to assume risks based on their risk-based capitalization, not to mention expertise and technical know-how in service delivery,” he said.

“To be forced to provide healthcare packages to a market it is not prepared to undertake would be against their rights as corporate citizen of the Philippines, not to mention the possibility of a failed business venture that will not only affect the ‘seniors’ amongst their planholders, but all their planholders in general, not to mention leaving a lot of unpaid bills with affiliated hospitals and accredited doctors in case of closure,” he added.

There are 23 HMOs operating in the country with over four million planholders. HMO regulation has been transferred last month from the Department of Health (DOH) to the Insurance Commission.