PhilHealth coverage and ‘folk illnesses’

Last Wednesday I explained why we need a government health insurance system like PhilHealth, and who can become members and beneficiaries. Today we’ll go into some of the medical expenses that can be covered.

The information I’m using comes mainly from Dr. Mads Valera, the senior vice president for health policy at Philippine Health Insurance Corp. (PhilHealth) , who very kindly gave me three hours to run through some of the more important benefits. We also had some interesting discussions about bangungot [nightmare] possibly being a genetic problem, and which I’ll share in a future column. (If you need some information right away, you can look at my book, “Revisiting Usog, Pasma, Kulam.”)

Last Wednesday I gave a pop quiz eligibility for PhilHealth membership. Let’s do another pop quiz about coverage. Which of these are covered by PhilHealth: natural deliveries, dialysis, cataract operations, liposuction? Let me make it more difficult by asking if usog, pasma, kulam and bangungot are covered.

Usog and other “folk illnesses” are not covered by PhilHealth unless two important conditions are fulfilled. First, your physician must give a diagnosis for a condition that is recognized by Western medicine and by PhilHealth (e.g., bangungot might actually be a heart problem called “long QT syndrome,” but then that syndrome still isn’t recognized by PhilHealth); and second, your expenses for treating the recognized illness must be incurred during hospitalization, and this can include room and board, some diagnostic procedures and medicines.

Maternity packages

Let me give you the answers now to the other questions in the pop quiz.

For a long time, only caesarian deliveries were reimbursable, a policy which was criticized because it seemed to encourage both patients and obstetricians to go for a caesarian even if it was not necessary.

PhilHealth has since modified that policy, offering a “maternity care package” that includes “spontaneous natural deliveries.” The package is for P4,500, with plans to increase this to P6,500. The package can be used both in hospitals as well as in accredited lying-in clinics, but not for home deliveries.

The expansion to include lying-in clinics is a welcome one because many low-income Filipinos prefer going to a lying-in clinic, which is cheaper than a hospital. The P4,500 reimbursement goes a longer way to cover costs incurred in a clinic rather than in a hospital.

In principle, the maternity package can cover pre- and post-natal care as well, but PhilHealth is still fine-tuning how this can happen, and what would be included for pre- and post-natal care.

Let’s move on with the pop quiz. Yes, hemodialysis is covered if it is used for end-stage renal disease. In terms of reimbursement payments made by PhilHealth, hemodialysis was in fact at the top of the list in 2008. (In terms of actual payments though, caesarian deliveries topped the list, PhilHealth paying out P2.6 billion.)

Cataract removal? Again, yes, this is covered, and is an important benefit for the elderly.

Cosmetic vs reconstructive

Finally, liposuction. Even if the liposuction is conducted in a hospital, technically, it would not be covered because cosmetic procedures are not covered. Note though that some “reconstructive” procedures are covered. PhilHealth uses the definitions of the Philippine Association of Plastic, Reconstructive and Aesthetic Surgery to make the distinction: “Cosmetic surgery is surgery performed primarily to improve or change a person’s appearance, which is already normal but may not conform to one’s self image. In contrast, reconstructive surgery is performed primarily to improve or correct body deformities resulting from trauma, disease or birth defects.”

Here’s a concrete example of how this distinction is made: silicone breast implant would not be reimbursable if done only for “cosmetic” purposes, but if it is done after the removal of breasts (e.g., in cancer), it would be considered “reconstructive.”

PhilHealth relies on medical specialists to draw up guidelines to what illnesses and medical procedures can be reimbursed, and it’s almost fascinating to look at how they evaluate the cases.

There are many debates on what procedures should be covered. Cosmetic procedures are not reimbursable because they’re considered too much of an individual concern, without any life-threatening implications. In richer countries though, some cosmetic procedures are allowed—even sex reassignment, for example—because the low self-esteem of the individual might lead to serious depression, or even suicide.

Rare illnesses are also generally excluded in PhilHealth, but one could argue, too, that precisely because they’re so rare, and expensive to treat, society should help the patient and his or her family.

For a country like the Philippines, priorities need to be built around what’s most needed by the majority of the population, and right now that would mean the poor. PhilHealth’s important “if” for reimbursement is hospitalization and this ends up excluding many basic medical procedures that the poor need. For example, I was asked for help recently by an employee whose father was having problems with urination. The urologist had ordered ultrasound to determine if there were stones or not, and a PSA to see if there was prostate cancer. The family could not afford the procedures, but asked around and were told that if they checked into a hospital, the procedures could then be performed and reimbursed through PhilHealth. It’s a roundabout way, and risky in the sense that they could incur more expenses around the hospitalization than PhilHealth will cover, but that’s how health care works (or doesn’t work) in our system.

PhilHealth helps to make it easier to survive in our system, but we need to do our part as well, making sure our employees, including household help, are covered. Meanwhile, expect more voices to be heard from socially-oriented physicians to continue to expand PhilHealth’s coverage. With elections around the corner, we might want to pressure politicians as well to be clear on how they view PhilHealth’s role.


By Michael Tan, Pinoy Kasi, Philippine Daily Inquirer, May 22, 2009