Fraud in PhilHealth

The Department of Health has a list of the 10 leading diseases in the Philippines. The marquee illnesses are there—heart disease, diseases of the vascular system, pneumonia, tuberculosis, diabetes, cancer, hypertension, dengue. Cataract, an eye disease common among people over age 40 in which the lens of the eye becomes clouded and loses vision, is nowhere in the list.

You would think, however, that there has been an epidemic of the disease lately, with the news that removal of cataracts was the fourth top medical procedure paid for by the Philippine Health Insurance Corp. in 2014. The tab amounted to an enormous P3.7 billion out of the total P78 billion that PhilHealth shelled out last year as benefits payments for its member-patients.

Even more startling are reports that the majority of the claims for cataract operations came from a small group of around 10 ambulatory surgical centers that had apparently cornered the business for such medical procedures, with a turnover rate that beggars reasonable belief. It has emerged at the Senate blue ribbon committee hearing now looking into possible fraud in the PhilHealth claims, for instance, that just one doctor at Pacific Eye Institute—one of the 10 centers red-flagged as exhibiting “a very conspicuous rise” in claims—was able to perform 3,023 cataract operations in two years. Pacific’s bill to PhilHealth eventually amounted to P36 million.

But the suggestion of padding, of bloating the numbers, to be able to claim higher reimbursements from public funds, may not even be the worst part. Patients have come forward with stories of losing an eye or going blind from cataract surgeries that were unnecessary to begin with, or were done poorly, from the scarce information given them that would have allowed them to make better informed decisions before the operation, to the crucial follow-up checkup that did not happen according to established medical protocols, affecting the success of the surgery.

The case of PhilHealth member Romeo Fernando is instructive—and heartbreaking. In 2012, the Borough Medical Care Institute—also among the 10 surgical centers under investigation—performed a cataract operation first on his left eye, then, three months later, on his right eye. He was told that no follow-up checkup was necessary. But when his eyesight deteriorated further, Fernando consulted the Pacific Eye Institute, where he was made to undergo four laser treatments on the left eye. He was told his right eye was beyond repair—a diagnosis confirmed by the Philippine General Hospital which said his right iris had been pierced and irreparably damaged. Fernando is now blind in one eye.

But, despite the botched operation, his procedure was among those for which the two clinics received payments from PhilHealth.

The bogus cataract claims appear to be only the tip of a massive scam to defraud PhilHealth. Two hospitals have also been red-flagged following a spike in their claims for payments, this time for pneumonia cases, which constitute the top medical condition under PhilHealth’s coverage in 2014.

PhilHealth president Alex Padilla said at the Senate hearing that what the as-yet-unnamed hospitals were doing appeared to be a case of “upscaling.” A simple patient coming in with a cough or sore throat is recorded as suffering from pneumonia, thus bloating the hospital’s bill to PhilHealth. PhilHealth’s rates for pneumonia are nothing to sneeze at—P15,000 for moderate-risk cases, and P32,000 for high-risk cases. The total payouts for pneumonia cases last year was a whopping P7.6 billion.

Some institutions may have seen that as easy money. One of the hospitals under investigation, a 44-bed affair in a province, is said to have filed claims for pneumonia cases much higher than those at the high-end St. Luke’s Medical Center in Manila.

The good news is that President Aquino has just signed a bill that automatically enrolls the country’s 6.1 million senior citizens under PhilHealth. The measure goes a long way toward giving more Filipinos, of whatever age and station in life, a modicum of healthcare coverage guaranteed by the state.

The bad news is that PhilHealth itself may not survive for long—if the government is unable to get to the bottom of the fraud and deceit that are robbing it of billions of pesos in much-needed funds, and eventually harming its sustainability over the long term. Those counterfeit cataract cases may be real in one aspect—in the apparent willful blindness of some people in and out of PhilHealth to check the organized swindling happening in their midst.