Turning a blind corner

The ongoing legislative inquiries by both chambers of the 16th Congress on the alleged padded claims by certain unscrupulous hospitals, eye clinics and doctors from the Philippine Health Insurance Corp. (PhilHealth) have raised fears and concern, especially among us paying members. This may have unsettled the financial condition of the state-run health insurance agency.

The congressional inquiries have so far found most of the claims involved payments charged to cataract surgery performed on thousands of patients. The medical procedure is among those covered by PhilHealth for its card-bearing members all over the country.

The Senior Citizens party-list suspects that PhilHealth is using the controversy as a smokescreen to hide its true problem: its inability in the very near future to pay all of the claims for cataract operations. But Department of Health (DOH) Secretary Janet Garin quickly belied such concerns on the PhilHealth’s alleged “running out of money” amid complaints that services are not being rendered to them because payments were suspended. 

Per DOH estimates, there are around 400,000 cataract patients in the Philippines. A cataract procedure for one eye would cost PhilHealth P16,000. This amount is split between the doctor and the facility where the procedure is done. When I had sore eyes last week, my doctor charged me double.

If a patient needs to have a cataract procedure for both eyes, that will, of course, double the cost for PhilHealth. If all of the 400,000 cataract patients seek treatment, this could amount to a whopping P12.8 billion for PhilHealth.

No wonder PhilHealth is in panic mode and attempted to stop the program reportedly while they are trying to plug the loopholes. Unfortunately, such decision will leave 400,000 Filipinos in the dark – literally. PhilHealth clarified though they merely suspended payments to suspected eye clinics that have questionable claims.

At the resumption of the Senate Blue Ribbon Committee public hearing yesterday, PhilHealth chief Alexander Padilla disclosed payment for cataract operations stopped only for two eye centers under investigation. The rest of the almost 2,000 other eye centers where members can avail of services can still charge their claims to PhilHealth.

Cataract is the main cause of blindness in the Philippines. And this is what prompted the DOH to announce only last September that they will team up with PhilHealth to ensure indigent Filipino eye patients will be able to get cataract surgeries for free.

The problem is PhilHealth doesn’t seem to be up to the task. A World Health Report in 1998 also said developing countries like the Philippines must perform at least 3,000 cataract surgeries per million, or 300,000 surgeries in the case of the Philippines.

Last year, Padilla revealed PhilHealth paid P78 billion in insurance benefits. Of this total, according to him, P7 billion was paid for patients supposedly suffering from pneumonia; P3 billion for dialysis treatment; P3 billion for cesarean section procedures; and, P2 billion for cataract operations.

Certain eye doctors allegedly were doing cataract removal just to claim higher PhilHealth payments even if such procedure was not necessary. Some of the patients testified at the last Senate public hearing and one of them went blind after the procedure.

But must the rest of cataract patients suffer while PhilHealth is taking time to resolve the accusations against erring eye centers?

Sen. Teofisto Guingona III, who chairs the Senate Blue Ribbon Committee, in fact, found out to his dismay that these questioned claims have not been resolved for the past four to six years. In exasperation, Guingona castigated in particular the appeals body of PhilHealth for sitting on over 80 cases involving alleged offenses committed by eye centers, clinics and other facilities that were filed as far back as 2003 and dragging on to date.

To reduce the cataract backlog – let’s take a closer look. On its website, PhilHealth says it has more than 86.2 million members. More than half are indigents and their dependents enrolled to the system through various means, mainly through sponsorships by local government units and the government’s own 4Ps program.

The lofty target is universal health coverage, and PhilHealth likes to boast that it has covered around 87 percent of the population by the end of 2014. Unfortunately, PhilHealth’s weak financial position is revealed by just one particular procedure that it covers. Yes, cataract surgery.

The Senior Citizens party-list – because many of the cataract sufferers are from their ranks – rightfully decries PhilHealth’s unilateral refusal to pay the doctors and eye clinics that had performed such procedures pending resolution of alleged fraudulent claims and overcharging.

The eye clinics themselves are refuting PhilHealth’s allegations of padded claims. Yesterday, one of two eye centers whose accreditation and claims payments were suspended also appealed for the speedy resolution of the cases because of the serious impact this would have on the rest of their patients waiting for surgery.

But what if the padded claims are the works of people within PhilHealth? What if PhilHealth really is in financial trouble, never mind that it granted billions in bonuses to top executives last year?

Testifying at the public hearing yesterday, Garin explained the fund being used by PhilHealth is not all government money. It consists of members’ contributions, as well as some P38 billion from “sin” tax revenues. 

The real victim in this controversy, of course, are the poor Filipino patients who badly need cataract surgery. They look up to PhilHealth’s coverage to cure them from the dreaded eye disease only to be dashed by PhilHealth’s decision that effectively shut down the eye clinics by their refusal to pay the pending claims.

Where do the cataract sufferers turn to now? Our government hospitals are not that well equipped and could not accommodate all patients lining up to undergo the needed procedure. The lines grow by the day, to no avail. 

President Aquino’s “Tuwid na Daan” policy being implemented at PhilHealth may literally be turning a blind corner if Congress investigations on these cases lead also to nowhere. Worse, if this becomes a classic case of the blind leading the blind.