Health is welched

IF, AS THEY SAY, figures do not lie, state-owned Philippine Health Insurance Corp., or Philhealth, may be in some deep odorous substance.

PhilHealth recently hit the news in a big way when its officials, led by president and CEO Alexander Padilla, appeared in the hearings of the Senate blue ribbon committee and accused eye doctors and eye clinics of multi-million peso irregularities.

Among the issues that Philhealth officials raised in the hearings were the alleged padded insurance claims for cataract surgeries that the evil criminal heartless eye doctors supposedly submitted to and collected from Philhealth.

According to the Philhealth officials, a few eye doctors claimed some P500 million in insurance from the government corporation.

It was not clear in the hearings why the sole government health insurance company did not have enough safeguards against those supposed scams. Philhealth also had yet to come out with solid proofs to back up the claims made by its officials, under oath, in the Senate hearings.

Philhealth has reportedly closed its payment windows for all eye doctors and private eye clinics that offer cataract surgical procedures to PhilHealth members, millions of them.

Question: What would happen to poor Filipinos, particularly the elderly, in dire need of treatment for cataract and other eye ailments that the government, under the Aquino (Part II) administration, covered with general health insurance?

The answer should only be, well, they would have to suffer.

From what I gathered, an organized group of senior citizens had launched a mass campaign against Philhealth for suspending its program for cataract surgeries.

Philhealth has withheld all payments for insurance claims filed by eye doctors and private clinics that had performed cataract operations on Philhealth members. Why?

Word went around that Philhealth had to stop the free cataract surgery program because it got worried that the huge cost of the program could weaken its finances, if not totally wipe out the insurance firm.

Like it or not, the figures were not in favor of Philhealth. According to the Department of Health, to which Philhealth is an attached corporation, there are some 400,000 people afflicted with cataract in the country at present—and still counting.

Cataract is the leading cause of blindness in the country. The number of patients is expected to increase, because the disease has something to do with aging.

As the citizenry ages, according to sources in the ophthalmology profession, the number of cataract cases goes up proportionately.

Based on its official figures, Philhealth had some 86.22 million members in 2014, which means about 87 percent of the population had health insurance coverage.

The Aquino (Part II) administration went all out in its delivery of health insurance, perhaps emboldened by the increase in revenues coming from the “sin tax” law, which required the collection to go to public health care.

What Philhealth forgot to announce when it closed its insurance windows for cataract surgeries was that more than 4.33 million of its card-carrying members (as of 2014) were senior citizens and their dependents.

Guess what—they were all made “entitled” to the free cataract surgery benefit in the Philhealth insurance scheme.

Otherwise, the Philhealth “insurance cards” would just be that, mere plastic cards! In short, useless.

On top of the substantial exposure of Philhealth to insurance claims of the elderly, would be the more than 40 million indigents and their dependents that the Aquino (Part II) administration had gifted with Philhealth membership.

The cost to Philhealth of all those cataract procedures was frightening, indeed. The surgery for one eye alone would cost Philhealth about P16,000—it would double per person within a lifetime. The disease affects both eyes in the long run.

With the estimated number of cataract patients that received from the administration those Philhealth cards—some 400,000 as of last count—Philhealth would have to shell out some P12 billion, easily.

Would Philhealth have that kind of money for just one type of procedure to address the claims on just one kind of ailment among its 86 million plus members?

Philhealth actually bit more than what it could chew, as part of the so-called reform program of the Aquino (Part II) administration, when it enrolled 86 million in its health insurance program.

As I said, by the very nature of the eyes disease, a good number of people suffering from cataract would be senior citizens.

Still, according to our contacts, a high incidence of cataract would also be detected among the poor due to poor diet.

In other words, those afflicted with cataract would be the very sectors that would have no other means to obtain treatment other than their Philhealth membership.

And Philhealth just suspended its grant of insurance claims for the procedure.

From what I gathered, Philhealth did not only suspended “future” claims, it also refused to honor the outstanding insurance claims of private clinics—whether or not the clinics were among those suspected of perpetuating the alleged scam.

It would be easy to imagine what could happen to those clinics. Yes, of course, they would simply shut down, with millions of pesos in investments in new equipment and modern facilities presumably gone, too.

As I said, many of those clinics did not have anything to do with the alleged scam exposed by the Philhealth management in the Senate blue ribbon committee hearing –without any proof, at that.

It would not matter to the Philhealth management that the insurance corporation itself accredited those clinics, as much as Philhealth itself screened and approved the procedure for each and every patient who had undergone the surgery.

By the way, Philhealth accredited private clinics to treat its members, precisely because the government did not have the infrastructure (i.e. hospitals) to honor the insurance claims of Philhealth members.

From now on, Philhealth could just direct its members to go to government hospitals like the Philippine General Hospital.

According to some patients that appeared as witnesses in the Senate hearings, Philhealth would only have one problem: The government hospitals would not have the equipment and doctors to perform the cataract surgeries.

Finally, Philhealth also has to cover other claims, such as childbirth (both normal and C-section, from what I gathered), radiation therapies, dengue, typhoid and hypertension, to name a few.

Would you say that Philhealth would just have to welch on its health insurance obligations sooner or later? I thought so, too.