In order to address issues and concerns on supplemental guideline affecting the implementation of circulars for pneumonia and ICD-10 code and category titles related to chronic kidney disease including policy statements implementation on the diagnosis of acute gastroenteritis, urinary tract infection and community acquired pneumonia, PhilHealth XII Reach Out Team conducted a forum with health care providers in the City of Koronadal on March 29, 2016.

“Before implementing new policies I think, PhilHealth has to consider the fact that the practice of medicine is an art. How we treat our clients, how we handle individual cases depends on our applied knowledge. After all, what we deliver is always for the wellbeing of our patients. PhilHealth should not dictate ... Please allow us the freedom to exercise our own clinical practice guidelines (CPGs),” SOCSARGEN Chapter Philippine Hospital Association President and Medical Director of RO Diagan Cooperative Hospital, Dr. Renato O. Diagan said.

Implementing the new policies like requiring them to conduct series of laboratory tests for pneumonia and UTI is according to them imposing something against their freedom to exercise their own CPGs.

“Why require us to extend the member’s admission up to 4days if in 2 days time the member is already responding well and regaining physically? That only adds financial burden for indigent and sponsored members. It also affects our operating cost because as patients extend their length of confinement, the more electricity and water is utilized. That adds to our bill and human resources expense considering that we are paying our nurses and med-techs as well,” other hospital owners further said.

If only PhilHealth according to them will consider the limitation of laboratory tests and allow them to exercise their own call of judgement in terms of delivering services to the patients, it will foster harmony in the partnership.
PhilHealth Reach Out Held
Accreditation and Quality Assurance Section Head, Dr. Antoniette M. Ladio talking about PhilHealth’s policy statements implementating the diagnosis of acute gastroenteritis, urinary tract infection and community acquired pneumonia
Intensive Care Unit (ICU) admission for high risk pneumonia was likewise asked and the panelists headed by the Accreditation and Quality Assurance Section, Dr. Antoniette M. Ladio answered that ICU is only required whenever necessary.

“It does not follow that high risk pneumonia patients must really be admitted at the ICU. If you have read the policy, it states that it is only recommended. Sometimes some cases are not really pneumonia. It might be another case,” he said
PhilHealth Reach Out Held
Benefits Administration Section Head, Dr. Henry F. Manzares answering questions during the Stakeholders’ forum held at Villa Amor last March 29, 2016
Head of the Benefits Administration Section, Dr. Henry F. Manzares on the other hand added that PhilHealth requires laboratory tests for pneumonia like chest x-ray and blood culture because the corporation wants an evidenced based treatment.

“How can we confirm that what you are claiming from us is indeed a high-risk pneumonia case if there are no evidences that a patient is suffering from such without those tests? It might not be pneumonia. It might be another case if the result is negative,” he said.

It was stressed that as administrator of the National Health Insurance Fund, PhilHealth is only trying to have its mitigating measures in order to ensure that what is really paid for by the corporation equates the right and correct measures provided by the health care providers to the members.

Ladio further said that PhilHealth XII ranked third in the Philippines with the highest number of pneumonia cases.

“We may give due consideration to your suggestion and recommendations …we may eliminate laboratory tests if you can guarantee us that what you are trying to implement is based on actual studies conducted and currently being practice… Put them into writing through your national organizations and we will let our policy makers decide on it,” Manzares added.

As the majority silently agreed, one doctor stood up and asked if indeed PhilHealth is losing why it has to strictly impose its new policies.

Fund Management Section Head, Mr. Edwin M. Tanteras replied that it is not because of its 128B reserved funds.
PhilHealth Reach Out Held
Fund Management Section Head, Mr Edwin M. Tanteras asserts that PhilHealth accredited health care providers have nothing to fear because of the 128B reserved funds.
Local Health Insurance Office Head, Mr Nol S. Valila added that the issue only came out after a certain Board Member was interviewed and misquoted.

“It’s a fact that we have only collected 96B last year and have paid 97B for you as our partner providers. But it doesn’t mean that we are losing. We still have 128B reserved fund. If the same scenario will happen again next year and in the succeeding years, we still have 127 years more to live,” Valila stressed.

One facility owner likewise suggested that PhilHealth should strengthen its monitoring particularly with hospitals encouraging members of borrowing cards from others.

Manzares replied that PhilHealth has already identified facilities doing those fraudulent activities through its monitoring team.

One participant proposed for an increase of benefits not only for pneumonia but especially with UTI which covers only 6,ooo per case that currently requires at least 4day treatment.

Head of the Field Operations Division, Engr. Eugenio C. Donatos said that he understands the sentiments of hospital owners but he also explained that if they demand for higher benefits, paying members on the other hand must pay higher premium.

“I think it is an issue that we should understand. As administrator of this program, we are somewhere in between. We manage our members’ enrolment and we manage their hospitalization expense. If we will increase their benefits, we need to increase their premium. It takes another forum from the other end in order to settle this concerns,” he explained.

In closing, the Local Health Insurance Heads from Gensan, Kidapawan, Cotabato and Isulan guaranteed their presence to address more of the hospital’s problems in their respective areas. (HGN)

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