Of Philhealth Claims & Bonuses, PGH-ER and Ms Fely Sicam

Of Philhealth Claims & Bonuses, PGH-ER and Ms Fely Sicam



STREET ROUNDS – Under a soft drizzle after a fierce deluge along Commonwealth Avenue, I found myself talking to a friend, a fellow health activist and community health worker. The topic was about PhilHealth, Eye Centers, an article of Ms Fely Sicam about the PGH Emergency Room and yes, resident physicians as fake doctors.

She shared to me her own recent experience about an urban poor patient from their community who had stage 4 terminal breast cancer. The scene was the PGH emergency room. Rosa, not her real name, was brought in by a couple of community friends. She was in distress, in pain, had some difficulty breathing, and her blood pressure was on the low side.

My friend was fair enough to admit that Rosa’s case was a bit hopeless. She was brought to the PGH ER in the hope that some alleviating measures might be given to her to make her more comfortable, if not to buy her some more time.

BLURB 5To cut my friend’s story short, Rosa died a few hours later with no management (tests or treatment) done at all. I was shocked and asked her why? The reason was that her equally urban-poor companions did not have the money to buy even a bottle of dextrose, an IV line or catheter. They didn’t even have money to buy cotton balls! The PGH-ER did not provide these things for free.

I was shocked (for the second time). When we were medical interns in 1996, fluids, syringes, IV catheters, needles, povidone iodine, and other emergency materials were supplied by the hospital. We were already recycled gloves back then, but at least we can give emergent management to cashless patients who come in for help. How had it come to this state?

My friend went on to tell me things that she saw and heard while staying in the ER. She said there was a heart attack patient who’s been waiting for days to be admitted to the hospital’s ICU. There was a stroke patient who was being turfed to other government hospitals due to lack of beds.

She found out that their transfer from the PGH-ER to another government hospital has been delayed because even other public hospitals were in a similar situation.


At this point, I remembered the article of Ms. Fely Sicam published in the Mindanao Times under the opinion column “Loud Whispers: What a horrible scene at the ER of the PGH. (Arrogant nurses, Doctors without uniforms).”

In that piece, Ms Sicam described the PGH ER as being crowded, dirty, with no one personally attending to them, the resident doctors were not in white. There was no waste segregation and blood can be seen anywhere and everywhere.

In other words, walang ka-class-class na hospital.

This dismal scene is is not far from the truth.

On a daily basis, the PGH ER receives an average of 210-220 patients: 130 in the acute care, 50 patients who are ambulatory, and about 30 pediatric ER cases. At any single time, there are about 7-8 resident physicians on duty. Their tasks can become overwhelming and stressful such that 1-2 Emergency Medicine residents usually quit every year.

There are 49 nurses divided in 3 shifts for the day, or about 12-14 per shift. We know this not enough because most of the time, resident physicians are forced to do nursing tasks such as giving medications, wound care, etc.

The ER has daily supplies of medicines and basic emergency care. When these run out, patients will have to buy their own supply.

These situations should not come as a surprise since the number of government general and specialty hospitals have declined to 542 as of end-2013 (DOH Report 2014), from 721 at end-2009 (Arroyo Administration). This forces an ever growing population to crowd in fewer hospitals with unchanging or even decreasing human resources, facilities and supplies.


This is the effect of our government’s policy of PRIVATIZATION.

It began during the time of Corazon Aquino, the program was implemented by each and every successive regime including her son. In fact, it was during PNoy’s term that the iconic PHILIPPINE ORTHOPEDIC CENTER, the country’s only specialty trauma hospital, was privatized. It was sold to the group of Mr. Henry Sy, Megaworld-World Citi through a P2.9-billion loan from the Land Bank.

Under the privatization policy, budgetary support for national government hospitals is gradually decreased, to force them to become self-sufficient. It is therefore no wonder that poor people have become wary of going to these hospitals because nothing is free nowadays.

One might ask, isn’t PHIC supposed to cover for the health expenses of the poor?

In February 2015, the PHIC proudly announced that there are already 81.63 million people insured. That’s 4 out of 5 Filipinos with insurance!

Obviously, Rosa did not belong to this lucky group.


Data shows that only 33% of the lowest quintile of society, the poorest of the poor, availed their PhilHealth benefits (2014 DOH). In contrast, 88% of the richest quintile availed theirs.

Latest data also shows that out-of-pocket spending across all classes accounts for 58% of the total health expenditures of the country (2014). While that of PHIC only accounted for a measly 13%.

These figures imply that despite high PHIC coverage, having someone sick in the family is still a big burden for ordinary middle and lower class Filipino families.


Recently, PhilHealth officials announced that it paid out more than P2 billion for a total of 128,331 cataract surgeries in 2014. This amount is double than what it paid in 2011 (P1B) for 69,920 cataract surgeries. Coupled with this, the PHIC announced that they will be investigating top claimant private institutions for fraud, while suspending their PHIC accreditation.

This week, the PHIC announced that it has stopped paying two hospitals for upscaling simple cough and sore throat cases into pneumonia cases which has a case rate of P15,000 for moderate-risk, and P32,000 for high-risk.

Moderate-Risk Pneumonia is the top health condition PhilHealth paid for in 2014 with total 533,594 claims. This is equivalent to P7.6 billion out of the P78-billion total benefit payments that year.

Second and third on the list are hemodialysis procedure (691,489 claims) for P4.7B, and Caesarian delivery (217,754 claims) for P4.2B.

Interestingly, there were only 263,486 claims for normal spontaneous delivery package for 2014. That is an almost 1:1.2 ratio for Caesarian and Normal deliveries!

Of these top 10 cases paid by the PHIC, only pneumonia, diarrhea, UTI, and hypertension are also in the top 10 leading causes of morbidity and mortality for 2010 (no figures are available after this year).

This only goes to show that under a health system based on an insurance system, health priorities are not exactly the ones that receive the most funding.


Add to this the February 2015 Commission on Audit report questioning the state-run health insurer for giving its officers and employees P1.761 billion in unauthorized bonuses and allowances in 2013 despite official notices not to do so.

It therefore angers me to know that in 2014, the Department of Health gave 42% of its P83.7 billion budget (or P35.5B) to the PHIC in payment to cover the insurance of 15.1 million poorest Filipinos.

Why didn’t the DOH just distribute this money to the different government hospitals when it knows that most of poor who are truly sick often go to these hospitals? Why do they have to make these poor patients beg to their mayors, congressmen and governors for funds when they have this THIRTY FIVE BILLION PESOS to spare?

Worse, for this year 2015, the DOH even increased this amount to P37.1B. For what logical reason, I do not know. Do PHIC officials need more allowances and bonuses? Oh yes, it’s better to hear at the SONA that 15.4 million poor Filipinos now have PHIC ID cards.


But then we all know that only a small percentage of that 15.4 million really get sick to warrant hospitalization. And those needing hospitalization actually live far from the government hospitals making their PHIC ID cards basically a useless piece of… paper.

It would have been better if the DOH simply used their billions in sin taxes for preventive and curative measures. I’m sure P37 billion can buy enough medicines to treat cancer, cardio-vascular & infectious diseases.

They could have given these medicines for free or sold them at very affordable prices to poor patients who really need them. If they did, Rosa would still be alive today.

The government should provide health services, not insurance.


In the end, what should be questioned is how the country’s health system is being run and the policies that govern it.

It is the policy of privatization that encourages and forces private institutions and health practitioners to find ways to earn more from the system rather than strengthen it.

It is the system that has created another layer of bureaucratic officials who treat the people’s money as their own bonus kitty.

It is the same system that turned our outdated public emergency rooms into dirty, hot, crowded market places where doctors are forced to attend to an ever-increasing number of patients year after year after year.

It is the system that caused Rosa’s early demise.

And believe me, it will kill many more of our poor countrymen. Unless we act now, together, before it is too late.


– Dr. Darby Santiago

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