Defensor urges PhilHealth to end case rate policy

Anakalusugan party-list Representative Mike Defensor on Wednesday called on the Philippine Health Insurance Corp. (PhilHealth) to end its case rate system.

At a House committee meeting, Defensor claimed that the system has resulted in billions of pesos of losses from PhilHealth funds. 

"We would like to request the PhilHealth board who are here with us... at sa atin pong pangulo na magkaroon na ng malinaw na polisiya, at maging sa amin dito sa Kongreso sa ilalim ng administrasyon ng Pangulong [Rodrigo] Duterte, ay itigil na ang all case rates policy na nagiging ugat ng korapsyon sa PhilHealth," the lawmaker said.

A PhilHealth circular issued in 2013 aimed to phase out the state insurer's fee-for-service payment mechanism and replaced it with case-based payments.

According to the circular, case-based payment is a payment method that reimburses to healthcare providers a fixed rate for each specific illness or case.

Defensor said this system has led to PhilHealth paying hospitals the fixed rate even if the cost incurred by a PhilHealth member is much less.

Asked about a Commission on Audit report that there have been cases of overpayment in some PhilHealth regional offices, PhilHealth chief Ricardo Morales said they will check their records.

"Dun naman ho sa case rate, sa ilalim ng Universal Health Care law, papunta tayo sa global budget kung saan ang pondo ay ina-advance sa healthcare provider networks, sa LGU, sa probinsya, para sila na ho ang magmamanage ng kanilang pondo," Morales also said.

"'Yun ho ang longterm na sagot doon sa problema ng case rate na hindi naangkop sa angkop doon sa tunay na gastos," he added.

Under questioning by Quezon City Representative Bernadette Herrera-Dy later into the hearing, Morales confirmed that hospitals get to keep the remainder of the case rate that exceeded the costs incurred by the patient.

He said this incentivizes hospitals to be "efficient" and to give quality care to patients.

"Kung alam ng ospital 'yung case rate for a particular disease, mapipilitan ho siyang maging efficient na ang ibibigay niyang serbisyo at gamot ay papasok doon sa case rate," he explained.

He said PhilHealth inspects hospitals to ensure that the quality of their services is not compromised.

Herrera-Dy, however, said there is the possibility that hospitals may spend less on patients if it means they could keep the excess in the case rate.

The case rate system is one of the issues that has emerged as both chambers of Congress looked into alleged corruption in PhilHealth.

The Senate on Tuesday held an hours-long inquiry into alleged anomalies hounding the state health insurer, including supposedly overpriced IT equipment.

PhilHealth officials denied accusations by whistle-blowers that a "mafia" is operating within the agency. —KBK, GMA News