Pagsasauli ng sobrang pondo ng PhilHealth, legal nga ba? | The Mangahas Interviews

  • 2 months ago
Nasa P20 billion na raw ang naisauling pondo ng Philippine Health Insurance Corporation (PhilHealth) sa kabuuang P89.9 billion na kanilang sobrang budget. Ito ay alinsunod sa kautusan ng Department of Finance (DOF) sa mga government-owned and controlled corporations (GOCCs), kabilang na ang Philhealth, na ibalik sa national treasury ang kanilang mga sobrang budget para pondohan ang ilang proyekto ng gobyerno.

Maraming mambabatas naman ang umalma sa kautusang ito. Ayon sa ilang senador, ang pagkakaroon ng sobrang pondo ng PhilHealth ay patunay na hindi ginagawa ng ahensya nang tama ang kanilang tungkulin.

Ang depensa ng PhilHealth, alamin mula sa Senior Vice President of Health Finance Policy Sector at Official Spokesperson ng PhilHealth na si Dr. Israel Francis Pargas sa #TheMangahasInterviews.
Transcript
00:00:00The Department of Finance is returning almost PhilHealth's Php90 billion in non-expensive funds.
00:00:13Some are worried that PhilHealth members should be using it for more and added benefits.
00:00:23We will discuss this with Dr. Israel Francis and Dr. Ish Pargas, the spokesman and Senior Vice President for the Health Finance Policy Sector of PhilHealth.
00:00:36Good day, Doc!
00:00:38Good day, Ma'am Malu, and good day to all the listeners and viewers of our program.
00:00:45All right, Doc Ish. You have been with PhilHealth for 25 years and PhilHealth has been around for 30 years.
00:00:51What is this issue? Why do you need to return the Php90 billion that is parked in PhilHealth's fund and is not being used?
00:01:02Tell me, what is the legal basis for this?
00:01:05Yes, Ma'am Malu. Basically, this came from a Department of Finance circular where it is requested to get funds from GOCCs
00:01:26so that it can be funded by the unprogrammed programs of the government that do not have funds yet.
00:01:36The reason for the circular of the DOF is the GAA or the Appropriations Act of 2024 where there is a provision saying that the DOF can actually get all those money
00:01:57again to fund the unprogrammed activities of the government.
00:02:03We, as an institution also by the government, just followed this law and the circular but of course prior to doing so,
00:02:16we also sought the opinion of those offices which are actually overseeing PhilHealth like the GCG, like the OGCC and of course the COA.
00:02:29Their opinion is that we can give the money following again the law, the GAA and of course the DOF circular.
00:02:41Okay. So it seems like no one is questioning that the Department of Finance should return the funds that are not being used,
00:02:50all the government-owned and controlled corporations, around P200 billion in total, to fund the projects, especially the infrastructure that do not have funds yet.
00:03:03The problem is that people are constantly looking for the funds that are being used by PhilHealth.
00:03:09Isn't this a problem that your service is not enough?
00:03:16Well, first of all, Ma'am Malu, it is also in accordance with the law that PhilHealth needs to have a so-called reserve fund.
00:03:26And our reserve fund, there is a provision in the law that our reserve fund should have a ceiling that should be up to the maximum of two years expenditure as projected,
00:03:42so that we can compute. So even the law says that PhilHealth should have a so-called reserve fund.
00:03:50Now, it was also mentioned, I think, and it was also stated in the origin of this computation that this fund is not just for a year,
00:04:06but it is an accumulation of the funds that we do not spend or utilize to pay the benefits for our members through the years.
00:04:20So what they are saying is that this is an accumulation.
00:04:24But there are also those who ask why there will be such an accumulation while there are benefits or the benefits should be expanded for our members.
00:04:42Now, in our law, it is also stated that if we have an excess fund after the reserve fund, two things can be done.
00:04:53First, the benefits should be expanded or the contribution of our members should be lowered.
00:05:03If so, we have already started to expand our benefits since 2023 and until now, we will continue in 2024 according to our benefit plan and if we already have a benefit plan for 2025.
00:05:21So we are continuing to do that and we will continue to do that because that is approved and we have already reported that to Malacanang and we are also monitored by Malacanang that these benefits should be expanded.
00:05:42Doc Ish, how much should be the reserve fund of PhilHealth at any given time?
00:05:51At any given time, according to the law of RA 11223 or our Universal Health Care Act, it should be equivalent to two years of expenditures as projected.
00:06:08But that is what the ceiling says. So we need to compute from the previous expenditure and then we have to set at least two years as a ceiling for the reserve fund.
00:06:21How much is the reference expenditure? Is it 2023 or 2022 expenditure?
00:06:26For example, if the reserve fund is 2024, it should be two years of 2023.
00:06:33Correct. Is that MOOE or expenditures that are paid out to the claims?
00:06:40It should be in the benefit payout of our PhilHealth claims.
00:06:48Doc Ish, you told us that there is a Universal Health Care Law and you told your clients that all Filipinos, 110 million, should be a member of PhilHealth.
00:07:01But the issue is that they need to enroll or register. What is your real coverage to registered members, direct and indirect contributors?
00:07:13You are correct. In the release of RA 11223 or the Universal Health Care Act, it was stated that every Filipino is a member of PhilHealth.
00:07:25It was also stated that everyone should have immediate eligibility to the benefits.
00:07:30So if it's true, our coverage is 100% already coming from the law.
00:07:36However, it was also stated in the law that our members should be registered in our database.
00:07:44So our members also have a responsibility to register in our database.
00:07:53As of now, our registration is around 98%.
00:08:02Ms. Malu, I just don't have data if we will divide it to direct or indirect.
00:08:11So you mean 98% is not 98% of all Filipinos?
00:08:16Yes.
00:08:1798% of how many in absolute numbers?
00:08:20That is coming from our 110 million population.
00:08:26Okay. So 98% of 110 means almost 100 million enrolled and registered members of PhilHealth?
00:08:35Yes.
00:08:37Because the issue here is, it's okay if you have a lot of benefits packages and consultations,
00:08:47but the problem is, is it affordable, reachable, and accessible to register in PhilHealth?
00:08:55Because you need a card when you go to the hospital and you are confined, right?
00:09:02Well, Malu, in our Universal Healthcare Act, it was also stated that PhilHealth ID is not needed
00:09:12because as we know, PhilHealth is slowly turning into a system-generated.
00:09:21If we are already registered and in the database,
00:09:26when we enter the hospital, it will be checked on the computer if we are already registered or not.
00:09:33So it's easier to get benefits.
00:09:38For example, if we arrive at a hospital and we are already checked,
00:09:43and we are not yet in the registry or database,
00:09:46we will be registered by the facility so that we can be included.
00:09:52So that's one way.
00:09:53Second is, of course, we can register online.
00:09:57We already have that through our PhilHealth portal on our website.
00:10:03And of course, we can go to our offices where we have regional offices.
00:10:10We have regional offices and we have provincial or local health insurance offices nationwide.
00:10:18All right. That's right.
00:10:19Because the role of PhilHealth is very important as a health insurance.
00:10:23That's what it means.
00:10:25If you are sick or you are in the hospital and you need an operation, PhilHealth is there to help.
00:10:32But to be honest, you have a limit on the number of health incidents that people have.
00:10:40But if you are confined, sometimes, to be honest, there are drugs that are approved by PhilHealth to be covered or reimbursed.
00:10:48A lot of drugs are not.
00:10:50It's not in the formulary.
00:10:51Your hospital expenses are not just the room and the coverage of the disease in particular,
00:10:58but it can also be the doctor's fees.
00:11:02That's a big problem.
00:11:05Third, sometimes, other lab tests are not approved by PhilHealth.
00:11:11It depends on how many times it needs to be done.
00:11:14Especially for those who experience severe illness or palliative care.
00:11:19What is the problem?
00:11:20Because to be honest, if you have coverage, the amounts mentioned are okay.
00:11:25But if, for example, you have 1 million, sometimes, and your expenses are not covered by the doctor,
00:11:32up to 30-40% sum total can only be supported by PhilHealth, right?
00:11:38Yes, you're right, Ma'am Malu.
00:11:41What we feel is, of course, the demand of our members to expand and increase the coverage of PhilHealth.
00:11:51Because that is our mandate to provide financial risk protection in times of ill health.
00:11:57When it comes to medicines, we are limited in the law that we can only pay for medicines
00:12:07that are on the list of Philippine National Formulary or PNF drugs.
00:12:15It is also mentioned in the law, especially in the Universal Health Care Act,
00:12:20that if there are new medicines or innovative drugs or new procedures or equipment,
00:12:29they need to go through the so-called evaluation of health technology assessment
00:12:36and they should provide a positive recommendation if PhilHealth can pay them as an insurer.
00:12:44So that would include even the new diagnostics and even new equipment
00:12:51and even innovative techniques and procedures.
00:12:55So we are limited in the law.
00:12:58You're also right that we have a limit because the way we pay is through a package.
00:13:06We have a case-based push.
00:13:09For example, pneumonia.
00:13:12Pneumonia is a severe type of pneumonia.
00:13:16As of now, we have increased it and the package that we can pay is around Php90,000.
00:13:25You're also right that the bill of a patient is around Php120,000.
00:13:34So the answer of PhilHealth is Php90,000.
00:13:38When it comes to the professional fee, Php90,000 has a percentage of the professional fee.
00:13:48However, the PF of doctors is not controlled.
00:13:54So what is the plan of PhilHealth?
00:13:58We also came out of the Universal Health Care Act
00:14:02that if every Filipino is admitted to a ward or basic accommodation,
00:14:09they should not have to pay anything.
00:14:12And we are implementing that.
00:14:15And that is also in a government or public facility and a private.
00:14:23However, it is also stated in the law that if it's a government, 90% of the beds should be basic.
00:14:31If it's a private, only 10% of the beds should be basic or ward accommodation.
00:14:36So what are we looking at just to make sure that our benefits will be felt by our patients?
00:14:47Well, first of all, we are planning to issue co-payment rules or fixed co-payment rules
00:14:57where we will put a policy that if you are in a ward accommodation, you will not be paid.
00:15:07But if you are admitted to a regular private room or to a higher level,
00:15:14in a regular private room, we are looking at if we can issue a policy that the co-payment is fixed.
00:15:23So if it's 20% or 30% or just 40% so that our facilities and professionals will not be charged too much.
00:15:36We are also looking into coming out with benefit complementation with private insurances.
00:15:43So the benefits provided by the government like PhilHealth should not be duplicated with the private health insurances
00:15:55so that the benefits received by our members will be wider.
00:16:00And hopefully, we will be able to use that during the implementation of the reform of universal healthcare.
00:16:11Okay, let's do it one by one like a series of unfortunate or grave events.
00:16:19First, when you enter the hospital, is the emergency covered? No.
00:16:24When it comes to emergency cases, if we have a procedure done,
00:16:33as long as there is a procedure or operation done in an accredited facility, we will be allowed to do that.
00:16:40In the case of medical emergency cases, for now, we do not have a package,
00:16:48except if we have reached, I don't want to say death in an emergency room.
00:17:00But it is written in universal healthcare that PhilHealth should have an emergency package.
00:17:09For now, that is being studied by our so-called surge team.
00:17:15Hopefully, before or when 2025 comes, we will have an emergency package rate or emergency package services.
00:17:27It seems that people will feel the helping hand of PhilHealth
00:17:33because you will not be able to go to the hospital unless it is a chronic issue.
00:17:38It is a necessity, yes.
00:17:40Yes, it is often an emergency and often there is an issue of not being able to pay the deposit.
00:17:47So it seems that PhilHealth needs help.
00:17:50Second, the issue of acute communicable diseases like leptospirosis, is that covered?
00:18:01Yes, actually our leptospirosis, for now, we are paying for the leptospirosis package of P14,000.
00:18:12There are also increasing cases of dengue, we are also paying for that.
00:18:18The dengue fever is 13,000 and the hemorrhagic fever is 16,000.
00:18:27But we are studying to increase our dengue severe
00:18:34and we expect that before the end of the year, we will be able to release our expanded dengue severe package rates.
00:18:44Miss Malu, our patients, for now, including operations, we have around 9,000 packages.
00:18:54Alright, 9,000 packages.
00:18:56This is the limit of the fund that PhilHealth will provide but it is all-in.
00:19:03Doc, is it all-in? Medicines, hospital expenses, or rooms?
00:19:09Supplies, professional fees, room and board, and diagnostics.
00:19:14Alright, so it means that PhilHealth has help but it is still unfinished.
00:19:20What I would like to ask people is, when I go to the hospital, is it expensive to buy hospital items?
00:19:28Cotton balls, almost all of them.
00:19:34Yes, admittedly.
00:19:38If you have P13,000, P14,000, or P9,000, sometimes one or two days in the hospital and that's it?
00:19:49Yes, Miss Malu, and that is actually what we are looking into right now because our mandate is to provide the financial protection.
00:20:05That is why we are looking at two ways to help the first members.
00:20:14First, we are expanding our package rates.
00:20:19You know that this year, last February 14, during our anniversary, we increased by 30% almost all 9,000 package rates.
00:20:35Correct.
00:20:36Yes, and we are also looking into another round of increase of 30% again before the end of the year.
00:20:46There are specific cases that we are increasing like breast cancer from 100,000 to 1.4 million, pneumonia from 28,000 to 90,000,
00:21:02stroke from 28,000 to 80,000, 38,000 to 80,000.
00:21:10The second way to further advance the mandate of PhilHealth is to issue a policy when it comes to copayment.
00:21:27We will be able to regulate the payment of our members when it comes to a facility because you know that there is a big effect of inflation when it comes to pricing or prices of our health services.
00:21:49And that includes not only services of facilities but also even for professional fees.
00:21:55So we are looking at two ways on how we can actually make sure that our patients will feel the help that the government is giving.
00:22:08You're right Doc, but let's say there are a lot of concerns.
00:22:15Okay, you go to the hospital and sometimes your problem is where will you go to the hospital if you come from a faraway municipality or not PhilHealth accredited because it's a small hospital.
00:22:31On the other hand, when you get there, they will say that your package has increased, you can find a hospital, and they will increase the cost of the hospital.
00:22:41So it's like you're just in a hurry to increase the cost of the hospital and that's if you can find a hospital.
00:22:48Yes, you're right Ms. Maluno. Basically, one of our issues here is not only for PhilHealth but really for the whole health system is the access for those who will provide health services.
00:23:05So for now, when it comes to PhilHealth, we are not just accrediting hospitals to provide the services.
00:23:13We are also accrediting dialysis centers, freestanding, maternity care, animal bite centers, rural health facilities, and even primary care
00:23:28because we are also shifting our focus from curative to primary care.
00:23:34If you heard about our consulta program, we are also accrediting consulta providers which right now is around 2,600 accredited consulta facilities nationwide.
00:23:50But one thing we are also looking at, because you're right Ana, sometimes our members or our patients do not know where to go
00:24:02when they are told that you need to look at this, you need to go to the doctor, but they do not know where to go.
00:24:10And that is also one of the reforms proposed by Universal Healthcare Law where our health facilities will be a network of healthcare facilities from primary care to level 1 hospital to level 2 to a tertiary hospital.
00:24:38So if they are in a network and we are looking at that network, it is part of the network's work to guide the patient on where to go.
00:24:54For example, I went to primary care and the primary care told me that I need to see a specialist, a neurologist.
00:25:07The primary care will also tell you that here in our network, these are our neurologists,
00:25:14they are here in this clinic or here in this hospital, you can go to them.
00:25:20So that is also part of the work of our primary care practitioners.
00:25:28So that is one of the benefits of Universal Healthcare, to arrange a network to guide our members on where to go for complete treatment or for more information.
00:25:46You're right, Doc. It's a good idea to have a network, but PhilHealth has been around for 30 years.
00:25:53The dream back then was to reach 75% after 10-15 years of support value.
00:26:02But now, you're only reaching 30-40%. PhilHealth is helping health cases to have a network.
00:26:15Is there no mandate or requirement or obligation for PhilHealth to network all of that?
00:26:23Clinics, small health stations, big hospitals, primary, tertiary?
00:26:31The problem is when you get sick, you won't know where PhilHealth is accredited.
00:26:38Yes, Ma'am Malu. Actually, it is already mandated under the Universal Healthcare Law.
00:26:44But of course, we are partnering this together with the Department of Health because they will certify if a place is ready for us to contract as a network.
00:27:00Just to update you, for this year, we will already start piloting these networks.
00:27:10We will start in four provinces before the end of the year and we will contract them as a network.
00:27:19Hopefully, by 2025, there will be around 31 provinces where the Department of Health is ready to network.
00:27:30So by 2025, we can expand our contract with the network to provide and to provide services to our members.
00:27:42Doc Ish, let's go to the panic of hospitals and health service providers.
00:27:48They say that sometimes they don't want to go to PhilHealth because it's too late to pay.
00:27:55On the other hand, some patients say that there are hospitals where their cases are simple.
00:28:02Ubo and Cipon. Suddenly, they raise it to a more serious illness to increase the claim.
00:28:07Have you investigated these issues?
00:28:10How many hospitals do you think are right or wrong in saying that you are too late in paying the claims?
00:28:19And the patients are saying that there are hospitals that are over-claiming.
00:28:23Yes, Ms. Malu. Well admittedly, we really had a problem when it comes to paying our claims.
00:28:32There was a time when we had a backlog but that has been solved and PhilHealth is continuing to solve it.
00:28:41We also had an opportunity and we are continuing to do that reconciliation of admin data with regard to the data of the hospital
00:28:54so that we can set how much more PhilHealth needs to pay and how much more we owe.
00:29:04And so far, we are able to reconcile most with the hospitals.
00:29:10As you know, the process of PhilHealth, not all of the claims that are filed to us are paid or will be paid.
00:29:21There are claims that we are returning to the hospital because there are lacking documents.
00:29:29And those claims need to be returned to us so that we can process it again and see if it can be paid.
00:29:40There are also outright claims that PhilHealth is denying because it did not follow the policies.
00:29:51So we are returning that to the hospitals but they have the opportunity to appeal or reconsider if it can be paid.
00:30:04So those are the things that we are reconciling because there are opportunities that are still being denied by the hospitals
00:30:14even the claims that are denied or even the claims that we returned
00:30:20so that we can see what is the right figure that needs to be paid by PhilHealth.
00:30:27But so far, we are able to do those.
00:30:31There is already a clear and PhilHealth is already paying the so-called debts.
00:30:42Now when it comes to the issue of fraud, I just don't have the data.
00:30:48Most of them have cases or the ones that we are investigating when it comes to the issue of fraud.
00:31:00But yes, you are right. We have a department who does the investigation.
00:31:07We have a department who prosecutes and we have a department for the arbitration.
00:31:15You are also right, we have pending cases in all these departments and this is not only for facilities but even for patients,
00:31:29even for doctors, and some of also when it comes to the PhilHealth officers or PhilHealth employees who are complaining.
00:31:40Those information are good.
00:31:43First, to the hospitals, the claims should be settled but they are still asking for a fee from PhilHealth.
00:31:53In every 10 claims, let's say 10 to 100 hospitals, how many are approved, how many are denied and how many are contested because there is a lack of documentation?
00:32:07I think as of 23, for example, for the denied claims, we have around 3.5% and for the return to hospital is around 7 to 11% of the claims that we actually receive.
00:32:25So four are denied, about four for every 100.
00:32:32Around 11 are back to hospital for more documentation.
00:32:38So what is approved is 80 referral or 80 payout claims.
00:32:45Yes, around that.
00:32:47Okay.
00:32:48Not for every 10.
00:32:49If there are hospitals that are like recidivist, claiming over and over again, maybe that information should be made public to the people so they will not go there.
00:33:02Yes, you're right on that.
00:33:05We are actually thinking that it can be posted on our website but we are also looking into other matters like if there will be complications or how do you call it, effects when it comes to data privacy and all.
00:33:27So we are also looking into that because we also want to know, we also want our members to know who has these problems or facilities.
00:33:41Alright.
00:33:43Yes.
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00:35:02Alright, bye-bye.
00:35:04Yes, thank you.
00:35:05Goodbye.
00:35:06Goodbye.
00:35:07Goodbye.
00:35:08we need to look at that primary care so that we can see if we have a disease that should be given maintenance drugs
00:35:21and if not, we can order proper laboratories.
00:35:28For example, blood tests, cholesterol, triglycerides, diabetes, creatinine, ECG, x-ray, fecal occult blood test,
00:35:49and like what I mentioned, mammography and ultrasound will also be included.
00:35:57That's good news but it seems like the wellness and health conscious middle class will have an interest in that.
00:36:07Most of the time, if you are an indigent member, your health issue will be acute.
00:36:17It means that you need immediate help and the health facilities will be far away to consult, especially if you have an accredited 2,600 plus.
00:36:34So how is that? Do you have an income divide or do you have a picture of how many people are being consulted by income groups
00:36:44and how many acute or emergency needs help by income groups?
00:36:50Well, for now, I don't have data but so far, out of the 2,600 plus consulta providers, we already have I think registered more than 20 million
00:37:11because the consulta just started in 2022 and we already have around 20 million registered.
00:37:21When it comes to consulta, our members have a choice where they want to register.
00:37:33Because to answer our issue of being far away and all, they will choose where they want to register which is more convenient,
00:37:45closer to them and they will choose the accredited consulta providers.
00:37:52That's why we have a responsibility as a member of PhilHealth that we should register so that we can start taking care of our primary care practitioners.
00:38:09Whether we have an illness or we are well, we can continue without illness.
00:38:15Okay. Doc Ish, let's go back to the 90, 89 billion pesos. Did you get it all back or is it just 20 billion?
00:38:25Not yet. What we got back is around 20 billion and some are scheduled until the end of the year.
00:38:37But of course, Ma'am Malu, I think you know that there are groups that filed TRO in the court and so whatever will be the result of this and whatever will be ordered by the court, we will follow it.
00:38:59So it means there are 60 billion in PhilHealth that will decide what will be the decision of the Supreme Court because there is a temporary restraining order or petition.
00:39:12Now Doc Ish, the remaining 60 billion or even if we go back to 90 billion pesos, when the Department of Finance asked for it,
00:39:22didn't PhilHealth argue that if we had a choice, this 90 billion would have been spent on many more additional expanded services?
00:39:33For example, tuberculosis where our incidence is a bit high now, HIV AIDS.
00:39:40Well, of course, we also expressed with regard to our financial conditions and all.
00:39:48But again, I told you, we also seeked guidance from all other agencies that oversee or have oversight in PhilHealth.
00:40:01Their opinion is that we can give it as per provided by law and as provided by the circular.
00:40:14The difference is, actually this is what I'm talking about, even in TRO, health is a basic right, fundamental right.
00:40:24Unlike other GOCC that has excess funds that should be returned, maybe construction, infrastructure, their jobs.
00:40:36The difference with PhilHealth is that you are a health insurance and you have an obligation to increase or expand the coverage of your benefits instead of returning the money.
00:40:54Yes. If we continue to expand our benefits, I will just mention it, especially for 2024.
00:41:06So we have already released the increased packages of bronchial asthma and sepsis of the newborn.
00:41:14We have increased it by 30% across 9,000 case rates and we have also increased our package for dialysis from 2,600 to 4,000.
00:41:28And we have also released our new benefits when it comes to the coverage of severe acute malnutrition, which is part of our SDG commitment.
00:41:39And before the end of the year, we are still hoping to release our new package for dengue, severe as I mentioned, for cataract extraction.
00:41:52We are also expanding our benefits for peritoneal dialysis, chemotherapy for our cancers like lung, liver, prostate and cervix,
00:42:06and expanding our catastrophic cases like kidney transplantation, our coverage for cancer of lung, liver, prostate and cervix.
00:42:21And again, Ms. Malu, we are looking and studying now to have another round of 30% increase in the 9,000 case rates that we have already increased by 30%.
00:42:36So we expect that before the year ends, our case rates will increase by 60%.
00:42:43There is a statement from the employees of PhilHealth. They said that the money should not be returned, it should be spent.
00:42:52In fact, there is a big issue, the issue of provident fund for the employees.
00:42:59Please explain to me, is it appropriate to return the funds to the PhilHealth to start up a provident fund for the employees?
00:43:08Because people are confused, aside from the SSS, GSIS membership contribution, the funds for the provident fund, PhilHealth, you asked for the government's contingent fund,
00:43:24you can use it for the provident fund. Please explain, is it beneficial for the employees? Will they get the PhilHealth fund or the contribution from the employees?
00:43:35Actually, ma'am, we already have a provident fund and we are the one who contributes there.
00:43:43So it is reduced for all those who want to become a member of the provident fund, it is reduced for the salary of the employees.
00:43:54Okay. The statement of your employees, what do you think about that?
00:43:59It's like they have a pass at the ring. In fact, the rank-and-file, the benefit is low, but for the executives and for those who were reported last year, the allowances and bonuses are not enough.
00:44:12Ma'am, yes. But first of all, whatever bonuses we are getting now, all of that is related to the allowed by the government, allowed by the CSC and allowed by the COA.
00:44:31I think you also know that we are subject to all audits and disallowances because of disallowances.
00:44:43And those allowances were stopped by the COA and all other regulatory offices, we have already stopped them.
00:44:52So whatever is being received by PhilHealth now, it is only allowed by the government.
00:45:00All right. What do you think of the Senators? If you have a big fund, P90 billion in PhilHealth and you will return it to the Department of Finance,
00:45:11they should suspend the collection of membership dues or reduce it.
00:45:18Do you think this idea is not a good idea because the continuity of PhilHealth services to the members might be affected?
00:45:30Yes. Actually, the issue there is the sustainability. But you are right, there are suggestions that because of this, the premium might need to be reduced.
00:45:45That is also written in the law. If we have excess funds after the reserve fund, we can increase the benefit that we are doing or decrease the premium that others are proposing.
00:46:01If you can remember, during a Senate hearing also, our President and CEO, Mandili Desma, spoke.
00:46:12We are looking if we can suggest to Malacanang to reduce or suspend the premium contribution that is written in the Universal Health Care Act.
00:46:28At the moment, we are looking and studying if the fund can continue to increase the benefit and at the same time, reduce the premium because of the issue of sustainability.
00:46:46But Ma'am Malu, you are also right because currently, there are amendments to the UHC law.
00:46:57This is in the Senate and this includes the change of the premium contribution schedule that is written in the Universal Health Care Act.
00:47:10Okay. This includes the large group of OFWs that you will pay a premium here while they have health insurance abroad and they cannot get the benefit.
00:47:25So what is the status if there is an amendment? How can we protect our OFWs? There are a lot of them.
00:47:32Yes. Actually, you are right. This is where the discussion started that our OFWs have a request when it comes to this.
00:47:45But we should also remember that our OFWs have a family that is left here in the Philippines.
00:47:54They can use the benefit that they are being paid because our PhilHealth is a family insurance.
00:48:06We are not paying for ourselves but for our family and qualified dependents.
00:48:15So if we look at the data, I don't have it with me right now, our OFWs are using what they are being paid although what they are using is their family here in the Philippines.
00:48:33But this includes when it comes to the amendment, what is the best treatment when it comes to premium contributions of our OFWs.
00:48:56If there is a law and there will be a change, PhilHealth will definitely follow it.
00:49:04That's why they are fighting because the premium is 5% plus income.
00:49:11Yes. That is under the Universal Health Care Act. Now for this time, 2024, it is already at 5% as a basic P10,000 and a ceiling of P100,000 salary.
00:49:27Okay. So the 5% of your P100,000 salary is like P5,000?
00:49:35Yes. P5,000 a month divided equally between the employee and the employer.
00:49:42If it exceeds that, just like our OFWs, let's say it exceeds P400, P800 salary, the 5% will be painful.
00:49:53Ma'am, our computation would be at the ceiling of P100,000. If it is more than P100,000 salary, the computation is still at P100,000.
00:50:06So P5,000 a month.
00:50:09Yes. That's the maximum.
00:50:12Another problem that they consider in PhilHealth is the very political changeover of leadership.
00:50:20It's like you have a lot of connections. You have a long career.
00:50:24And you were already implicated in PhilHealth, you got sick, you got attention and you had an operation and a kidney transplant.
00:50:35But in reality, there are political appointees. Others have nothing to do with the health sector.
00:50:44Well, you're right there because the terms of our leaders are also in the law.
00:50:54When it comes to our composition of the board, actually for now, there are 5 or 6 doctors who are members of our board.
00:51:06And if we can see in our board members, of course there are representatives of our various branches of government like DSWD, DOF.
00:51:24And we also have an expert panel where the healthcare, financing and other members of the society are represented.
00:51:39But again, you're right that it is an appointed board of directors but there are qualifications as identified also in the law.
00:51:50Qualifications like? Because in the past, it was soldiers or investigators. Sorry.
00:51:57People are surprised. Why give such an important portfolio to people who are not connected to the health sector or health insurance concerns?
00:52:08Well, in the UHC Act, we already have identified experience, especially if you're an expert panel, that's the experience when it comes to financing.
00:52:25If you're an expert panel on the financing part, there are also those who require training and all.
00:52:33But of course, Ma'am Malu, I leave it to the wisdom of the appointing officer when it comes to that.
00:52:41All right. Now for the indigents, how do you provide support to them? Where does their membership premium come from?
00:52:51Who should pay? And is there a clustering? You said the four-piece families will enroll.
00:52:59Aside from them, who else will be registered?
00:53:03In the UHC, there are only two types of membership. One is the direct contributor and the other one is the indirect contributor.
00:53:14The only basis of this classification is the capacity to pay.
00:53:20So our direct contributors have the ability to pay, so that's where we are counted.
00:53:26Employees, self-employed, those with salary, OFW, and the indirect contributors, they don't have the capacity to pay.
00:53:39So that's where our government identifies the indigents, the four-piece, the senior citizens, the PWDs, and all others
00:53:55who don't have the capacity, it's in the law that their premium counterpart will pay, it's the national government.
00:54:04So technically, what we get as a subsidy from the national government is a payment for premium contribution of the indirect contributors.
00:54:16How many are there compared to the direct contributors? Do you have a mix, for example, 60-40, 50-50?
00:54:25Sorry, people don't seem to know because you said you have 98% coverage, but that's a lot of Filipinos.
00:54:33So if you have 100 million members that you cover or claim, how many are the indirect contributors?
00:54:42Ma'am Malu, I don't want to give any false numbers. I will inform you after this so we can give the exact numbers
00:54:52because that's also what the national government pays as a premium subsidy.
00:54:58All right. Now, national budget deliberation for 2025. What is your perspective?
00:55:05Will you have a hard time? Will you be questioned? Will you be reduced? What do you think?
00:55:11Would you argue your budget? You're seeking an increase of the total budget for 2025 in the amount of?
00:55:20Well, Ma'am Malu, we expect of course that we will be questioned, the budget requested by PhilHealth, which is of course under the Department of Health.
00:55:36Because I think the House and the Senate will just do its job before we can approve the budget concerns we request.
00:55:50And of course again, the budget we request is a premium payment for the indirect contributors.
00:56:01So we expect that with all the issues that are coming out right now, we will really be questioned.
00:56:09How much are you asking for from this year to next year?
00:56:15I think, I am not so sure, but I think it's around P75 billion to pay for the premium contributions of those listed indirect contributors.
00:56:31All right.
00:56:31It's smaller than what you will return, right?
00:56:35Well, yes. Basically, yes.
00:56:41All right. But in your reserve fund, what you're saying is equivalent to two years of expenditures.
00:56:48How much should you deposit? Does that mean your reserve fund should be around P150 billion?
00:56:54Other than what you will return?
00:56:56In the actuarial computation, I think for 2024, we will check on this, it's around more than P400 plus billion that we will need as actuarially projected reserve fund.
00:57:23All right. Until the year 2025? How many years are your actuarial projections?
00:57:29Our actuarial projections or the fund balance is until 2028 or 2029 in our computation.
00:57:38So your estimate is P400 billion until 2028, 2029.
00:57:44P400 billion reserve fund is what we will need to have a reserve fund for 2024.
00:57:52So by 2025, we will compute again dependent on the expenditures of 2024.
00:58:01So that's how we will compute. Every year, we need a reserve fund dependent on the previous expenditures and then it will have to be a two-year computation.
00:58:14I have two questions because you're the head of finance policy.
00:58:20This filial is investing in the money market.
00:58:22The government is buying from the money market. What is that?
00:58:26What happened? Is this just a leftist thing?
00:58:30Ma'am Malua, just to check, the health finance policy sector is a policy sector with regard to PhilHealth benefits.
00:58:44These are the packages. This is our health insurance coverage.
00:58:49But the fund management sector is different which actually handles the investments, the controllership, and the treasury.
00:58:59And the actuarial sector is different because it computes for the projections of our funds.
00:59:10That's why they should answer because the money is just going around.
00:59:15My second question is, the Department of Finance said that there is a P1 trillion fund that is not yet being spent from the 2024 budget.
00:59:27This means that there is a fund that is not being used which calls attention to the absorptive capacity or disbursement rate of the government, not just PhilHealth.
00:59:39So why do we need to add more funds for the budget next year?
00:59:44And when will we get it from the GOCC?
00:59:47Ma'am, well I cannot answer with regard to the fund management.
00:59:57Okay.
00:59:59Yes, but what I can say when it comes to PhilHealth is of course we need the sustainability in order to make sure that we can continuously provide the benefits that our members should get.
01:00:18And we should also continuously improve on these benefits to make sure that our members will receive the financial protection that they should be getting.
01:00:30Alright.
01:00:31In your 30 years in PhilHealth, Doc Ish, I know that you are very diligent in your PhilHealth work.
01:00:44But if you were to score PhilHealth, in terms of performance, in terms of support value, how big is the impact that PhilHealth has made because you still have a long way to go with your 75% coverage and support value.
01:01:00It's like you're only halfway through, 30-40%.
01:01:03What grade would you give PhilHealth and if you could suggest the first three things that should be urgent reforms in PhilHealth, what would that be?
01:01:13Well, first of all, you're right that we still need to improve our support value.
01:01:22That's also true, especially what we're looking at now and what we're giving as proof is the out-of-pocket expense of our members.
01:01:36So for now, we're also setting our target that by 2030, our out-of-pocket expense should be reduced to around 30%.
01:01:52That's all.
01:01:54And hopefully with the reforms that we are doing, we would be able to achieve that.
01:02:02So with that statement, I don't think we can or I can give a 100% rating for PhilHealth because we can see that we still have a lot to do before we achieve our target when it comes to the so-called out-of-pocket expense.
01:02:28Well, whatever the first suggestions that PhilHealth should make, to make sure that we can actually provide or deliver on our mandate, one is the digitalization.
01:02:47We should be improving and we should move faster to our full digitalization to make sure that the processes and the operations are more efficient.
01:03:01And we are also looking that the digitalization might also help in the reduction of the fraud that is happening and that will also make the transactional service between us and our members faster and more convenient.
01:03:23So I think that's one thing that we should learn when it comes to, again, to make sure that we are providing a better service.
01:03:34Second is to continuously review on our benefit packages and actually in a more opportune time or in a faster way, we can increase our benefits to provide more services and benefits to our members.
01:03:58That would also include more regulations when it comes to payment and copayment.
01:04:07The third is making sure and expanding the access so that our members can really go and get benefits, especially in the JIDA areas because we know that the Philippines is archipelagic.
01:04:31We have more than 7,000 islands and it is different when you go from one island to another.
01:04:39There are islands that don't have health facilities yet.
01:04:43So that should also be the focus of PhilHealth to make sure that there is enough access for our members to get this benefit.
01:04:54Because it would be a waste if we have benefits but our members don't get it or don't feel it.
01:05:02Correct. Actually, they say that the out-of-pocket expenses of Dr. Orville Solon are more than 50% out-of-pocket personal expenses.
01:05:18This is, I think, an earlier study he made.
01:05:22He said that in the health sector financing, most of the available government hospitals are middle class or those with clear employment.
01:05:36So what you're saying is that from geographically isolated and distant places, disadvantaged areas, PhilHealth cannot reach them. Is that correct?
01:05:48Yes, that's also correct because not only PhilHealth but of course all other services because they are actually JIDA.
01:05:58But that is what we are looking at, that they should be able to receive whatever benefits are provided by PhilHealth.
01:06:08Because again, a mandate of PhilHealth, this is also for everyone, for every Filipino.
01:06:15Now what I would like to check, Ma'am Malu, is of course when it comes to the data of determining out-of-pocket expenses.
01:06:26Because of course, what we are paying to PhilHealth and what we are covering are for those essential services.
01:06:33So we also should disaggregate the data when it comes to the expenses of our fellow Filipinos in the essential and non-essential.
01:06:44Because of course, when it comes to our health expenses, there are also expenses for beauty or for medicines that are not necessary.
01:06:57And of course, those are not covered by PhilHealth.
01:07:02So we also need to look at those so we can measure our out-of-pocket expenses when it comes to essential services.
01:07:12But can we say that it is included in the mental health concerns of Filipinos?
01:07:19Well, you're right there Ma'am Malu.
01:07:22And just to say the list, we released our new mental health package and this is an outpatient mental health package
01:07:31because our mental health diseases requiring confinement, we are covering that in PhilHealth.
01:07:41So what we released now is a mental health package for outpatients that we started since the last quarter of 2023.
01:07:51Okay. Lastly, Doc Ish.
01:07:54I hope it will be clear because PhilHealth likes to actually rattle off numbers of coverage of pesos value.
01:08:03But in truth, because it's health insurance, it means you should be hospitalized or have a disease.
01:08:10And the money you're talking about is all-in, right? It's not cashed out.
01:08:18Just to be clear, the facilities where people are being consulted or being treated will be included in PhilHealth's support.
01:08:28Just to be clear, because some people might think, oh I can get help from PhilHealth, especially now that it's a time of rattle-off help.
01:08:39Yes. Actually, Ma'am Malu, it's not just help that others are expecting.
01:08:44Others are asking if they can get a loan from PhilHealth.
01:08:49But of course, you're right.
01:08:52Our process is not like that.
01:08:55For us, during a time of illness, we can help reduce our payment.
01:09:03So that's why PhilHealth is an automatic deduction in our bills.
01:09:09It's called and it will be deducted from our hospital or facility payment and we will be the one to pay.
01:09:18So that if there is a need for payment, it will be deducted or hopefully only a small amount of money will be prepared by our members.
01:09:30So it's not everything. It's not all of it.
01:09:34Just to be clear, because others might expect you to give them cash to pay for the hospital bills.
01:09:42Yes, we don't give them cash.
01:09:45But Ma'am Malu, I just want to clarify.
01:09:49When it comes to ward accommodation or basic accommodation, we really enforce it.
01:10:00And we force them to enforce that there should be no payment to any Filipino as long as they opt to be admitted in a basic or ward accommodation.
01:10:13So when it comes to those points, we can say that if we really enforce it and really follow our facilities,
01:10:26that's when we can say that everything is covered.
01:10:30If there are beds in the ward, that's another issue.
01:10:38Of course. I think there are a lot of things that need to be clarified by PhilHealth because you are in the scene right now.
01:10:46So there are information that you can share for them to understand.
01:10:51And the indigents or indirect members should really know where they will go to the health facility so they can have consultations and other services.
01:11:03And yes, that's why I'm also thankful to you, to those like you, who are asking for more clarification for the PhilHealth operations.
01:11:15And this, I think, actually helps also in disseminating the information.
01:11:21So thank you also Ma'am Malu for giving us the chance to explain and of course to provide more information when it comes to PhilHealth.
01:11:30But of course, like what others are saying, it is never enough.
01:11:35So we still need more avenues of informing our members so they can use and understand PhilHealth better.
01:11:45Maybe one good avenue is for the children to get consultations because if a member of PhilHealth has a family insurance benefits package.
01:11:55So for the children in primary care hospitals to have a health profile.
01:12:03Yes, that's right. And Ma'am Malu, what we are encouraging is for everyone to have a health profile so they can be taken care of.
01:12:13Because what we are saying is that our primary care is not just for those who have feelings.
01:12:19It is also for those who do not have feelings so we can maintain our health.
01:12:25Alright. So good luck with your budget hearings in the House of Representatives and in the Senate.
01:12:31I hope it can be clarified. And in the Supreme Court case, do you have any filings that were submitted in response?
01:12:40I'm not sure if we were asked to comment on that. But if we will be asked, we will provide our comment also, Ma'am.
01:12:49Alright. Dr. Ish, even if you are sick and you have an operation, you are still in PhilHealth.
01:12:58So I hope this explanation will continue and I hope there will be more services and more people will benefit from PhilHealth.
01:13:08Good day, Dr. Ish.
01:13:10Good day, Ma'am Malu. And thank you very much for the time.
01:13:14And I hope if you still have additional questions, PhilHealth is always open and they can always call us on our hotline 028662588
01:13:27or they can actually write to us at actioncenter.philhealth.gov.ph.
01:13:33Alright. Thank you very much, Dr. Ish.
01:13:38♪♪♪

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