April 22, 2009

Just for the information of our PAO members who may be wondering at the new RUVs of old and new procedures as released in the new PHIC circular and at the new cataract case payment system - I make the following situationers and clarifications. I had earlier asked Dr. Harvey Uy to post most of the following in the VRSP e-groups last April 1, 2009 when its members noticed that some of their proposed RUVs had not been followed by PHIC in its final list of approved RUVs. I had opted to elaborate more on some other issues as well.

1. When the PAO was asked by the PHIC to submit its proposed revised and new procedures for inclusion in Philhealth entitlements - we wrote the different specialty affiliate societies for the proposed inputs on the subject. This was first done during the previous council and the PAO thru its Committee on Health Insurance Matters and its President, had submitted the sanitized list bearing most if not all of the recommendations by the different sub-specialty societies. This list was re-submitted almost three times as requested by PHIC - with the final revised list submitted just early last year - after the list had a fourth pass review to make sure it contained most of the original inputs of the sub-specialty societies - since we saw some discrepancies between what we submitted and what Philhealth was using as a basis of their original master list of procedures.

2. However, it was made clear to us that the list, as submitted by even other specialty societies - would remain mere PROPOSALS and that the final action on them shall depend primarily on the recommendations of the Benefits & Research Department to the board of trustees and of course on the final approval of the BOT. I was made to understand that the decision shall partly be dependent on the "Related Disease Group System" of actuarial studies based on operating international health insurance systems - with modification based on local availability of funds and facilities. In this system, they group together ALL disease or clinical entities across the various specialties into different level categories and the into the procedures needed to manage each disease entity and then compare the "relative technical difficulty and delicateness" of a procedure compared with the other specialties' procedures - with factors on the clinical training and equipment required to do the procedure, level of disease severity (eg life-threatening conditions, etc).

3. As was the strong position & sole decision of the PHIC BOT upon recommendation of its technical committee, the RUV for cataract was made uniform for PHACO and ECCE and was pegged at 200 (the higher value of the two previous RUVs for ECCE and PHACO) - in anticipation of the case payment system that they had already anticipated and wanted in order to curb the abuse of mis-declaration or mis-representation of some unethical eyemds. They declared that case payment system shall be adopted for procedures with the highest utilization rates (again among all specialty procedures) based on their data on claims. They referred to their data that among the top twenty millionaires on Philhealth claims / reimbursements ALONE – eleven were ophthalmologists. And indeed cataract surgery claims ranked as one of the highest – next to spontaneous vaginal deliveries. So cataract surgeries are now in the league of normal birth deliveries - in line for case payment. As such the proposed case payment for cataract was pegged at P8,000.00 for surgeon's PF (200 x P40) based on the adoption of the new RUV for cataract procedures (whether ECCE or PHACO). The decision to exclude PF of anesthesiologists and for pre-operative consultation and / or physician standby service was THEIRS ALONE – despite our protestations on the matter. With your Council’s representation in the BDRD meetings we were able to suggest at least a P20,000 package – hoping that P2k can at least be appropriated for anesthesia care and P2k for pre-operative clearance (with the added proviso that should the eyemd not utilize their services – they can be free to allocate the extra funds to hospital related expense and devices on their own) – but our suggestion though considered was finally not approved.

They made it clear that case payment compensates for the procedure (cataract surgery) and not the technique (ECCE or PHACO) of the procedure! That is why it is called case payment. They pay you for the case of cataract surgery that you do. I had made strong representations to at least use the new PCF of P56 for computing the then about to be adopted case payment – prior to its implementation (if such had already been decided by the BOT) but they told me that it can no longer be considered since the case payment amount for cataract surgery had already long been decided upon and approved unilaterally by the BOT even before the three tiered payment system for professional fees was considered and approved! They further informed me that, while the case payment system for cataract had been approved some time ago - they had just postponed its implementation, while reviewing our suggested P20k case payment package – which they unfortunately did not approve. They also told us that its implementation may come during the second quarter of the year – and indeed the latest circular no. 16 s. 2009 indicates its implementation starting May 1. Now all case payments - shall no longer be based on RUVs and the new policy on tiered payment for doctor’s fee shall not apply to all case payment procedures!

4. In my last meeting with them just last week, we were told that while our wish list of new and restructured RUVs was duly received by them - they have made very few approval of modest increases and may have even decreased some - not only due to the increase in the PCF (20% for board eligibles and 40% for specialists) but due to the "related disease groupings" across the specialties.They particularly noted that they had lowered the RUV for vitrectomy - as was observed by the VRSP members – in part to at least contain their observation that “vitrectomies” seem to have been a regular part of routine cataract procedure in many of their questionable claims. Note that there is a proviso in the circular stating that only the cataract package shall be paid for claims that are accompanied by vitrectomy secondary to posterior capsular rupture.

5. As to the issue of the “three tiered payment of professional fees” for doctors and the presence of the 2nd level group composed “of physicians who completed residency training but are not specialty board certified” that straddle between “general practitioners and other physicians with no hospital training” and the “fellows and diplomates of specialty societies recognized by the PMA” – your Academy thru the President had written the Vice President for the Quality Assurance Group and had expressed our strong sentiments to do away with second tier level of non-certified specialists to better motivate our graduates towards a more focused and purposive self-improvement and to protect the health interest of Philhealth members. Note that, this does not even qualify if these “second level physicians” graduated from an accredited training program by the duly recognized certifying board for the specialty. It may in fact give benefit to graduates of a non-accredited training program that does not fulfill the minimum standards of a good training program.

The PAO is of the opinion that it behooves the national health insurance body to protect the interest of its members by making sure that if they go to a Philhealth accredited facility – they are assured that the health care professionals who shall attend to them are at the very least – board certified by the specialty discipline that they claim or profess to be trained and certified in. We further stated that this assurance can motivate the patients to preferentially seek “Philhealth accredited facilities” – since they shall bear the seal of good housekeeping with only certified specialists in their roster of health providers. This cannot be assured however, if we recognize a subset of “second tier of physicians” who are not specialists and who will not voluntarily give a full disclosure of their professional status before their unsuspecting patients. As such, the non-certified physicians shall hopefully have a greater motivation to strive to take and pass their certifying board exams to get the same professional compensation as their specialist counterparts.

Our above position is now under study though their main argument against our stand is “what do they do in areas where there are no certified specialists and specialty procedures have to be done by graduates of hospital training but are un-boarded?” Our response to this is to give them a GP level of compensation so as not to disenfranchise them totally. It however, should motivate them to take and pass the specialty board not only to elevate their compensation to a specialist level but to safeguard patient safety and thus enhance their image in the community where they serve.

Before, I end I wish to remind everyone that the Philhealth entitlements are to be viewed as mere subsidies for a procedure by an insurance system with its limitations on fund availability and prioritization of its equitable utilization. What is affected by these limitations are the decrease in the Philhealth’s capability in reimbursement of doctor’s fees and hospital related expense. It cannot be expected to fully re-imburse the real cost of a procedure and the qualified expertise of the doctor – especially as procedures become more sophisticated, equipment, device and specialty-training dependent. As some would put it, it should allow us to innovate, re-package and improve our services and it does not dis-allow us to charge more than what Philhealth can presently afford precisely because of the quality of work that we can render compared to others.

On the other hand, there is nothing stopping a practitioner who can accept to do a procedure on pure Philhealth reimbursement alone because of altruism.

Finally, I just want to remind everyone that Philhealth entitlement, both for the health providers and facilities, is a privilege and not a right. Perhaps this shall be the case even for patients at least for the meantime until a universal coverage of all citizens can be enacted and operationally implemented. Anyone who does not agree with the limitations of the system can opt out of it voluntarily because it is never forced upon anyone of us.

Rest assured however, that your Academy shall continually represent the interest of our members (as it had done in all the meetings with the various departments of PHIC) to a degree that is fair to all (the patients, our members, the health care facilities and Philhealth).

I hope the above clarifies matters that we are all concerned about.

Thank you for your attention and patience!

Rey E. Santos, MD

President, PAO

- Show quoted text -