How scalawags are draining limited health care resources | Lifestyle.INQ

OCTOBER 27, 2022

The engine of Universal Health Care (UHC), which aims to provide equitable medical services for all, has been cranked up with the passage of the “sin” tax reform bill last week by both the Senate and House of Representatives.

It was a very comforting message we got from the Senate, which unanimously voted for the passage of the bill. Senators look sincerely committed to making UHC work. When the original sin tax law was passed in 2012, it was a narrow victory when they voted 10-9.

We were confident it would be a more convincing victory this time, but the 20-0 vote for Senate Bill No. 2233 can go down in our legislative history as one of the rare times when lawmakers set aside all personal qualms to pass a landmark bill.

House Representatives likewise did their part for the swift approval of the bill, sans lengthy discussions.

This development is essentially a victory for low-income and indigent Filipino families, who need not worry so much anymore over how their diabetes, high blood pressure, chronic lung diseases and many common medical problems can be properly diagnosed and treated.

Risk factors

It’s relevant that poverty and other socioeconomic deprivations are now considered risk factors for many illnesses, and a major reason for a shortened lifespan. The poorer one is, the higher the health risk.

The real-life scenario shows that poor people have less access to adequate health care, which could have diagnosed diseases like cancer early enough to afford curable treatment, or to control lifelong diseases to prevent disabling and life-shortening complications.

The ironic part is that, sometimes, our financially challenged brethren have more vices—including smoking, excessive drinking and other unhealthy behaviors and lifestyles.

We hope that a significant fraction of the UHC funds will be allocated for disease prevention, to include sustained public and individualized health education to stress the importance of healthy lifestyle measures and positive health-seeking behavior.

If this major barrier to health care is not addressed, it’s like filling up a pail of water with many holes. So much resources are wasted instead of being used for more cost-effective interventions that can improve health care at the general population level.

Speaking of wastage of resources, I think we will have sufficient funds to finance UHC if we can significantly reduce the “hemorrhaging” from losses in PhilHealth due to fraudulent claims and overpayments.

It’s estimated that the national health insurance agency, which will play a pivotal role in UHC implementation, has been losing around P25 billion a year over the last six years. That’s around 15-18 percent of its annual operational budget in the same period.

Some losses may be inevitable, but aiming for a less than 3 percent loss from padded or fraudulent claims by some health care scalawags is possible, as has been shown by other health insurers.

We don’t have to reinvent the wheel. We can just locally attune health care planning-monitoring-controlling (PMC) systems that can be deterrents to fraudulent claims. These PMC systems can assess if medical services rendered are appropriate, efficient and effective through random reviews of medical records of accredited health facilities.


PhilHealth should also come up with guidelines or recommendations on strategies that have been shown to cut costs without adversely affecting quality of health care. Compliance with these guidelines can be made a requirement for renewal of PhilHealth accreditation of the health facility.

Some health insurers also use programs for detecting nonacceptable claims. Charles Piper published a paper detailing various schemes for defrauding health insurers. According to Piper, the 10 most commonly employed ploys by unscrupulous health providers include the following:

Billing for services not rendered
Billing for a noncovered service as a covered service
Misrepresenting dates of service
Misrepresenting locations of service
Misrepresenting provider of service
Waiving of deductibles and/or copayments
Incorrect reporting of diagnoses or procedures (includes unbundling)
Overutilization of services
Corruption (kickbacks and bribery)
False or unnecessary issuance of prescription drugs.

One important facet of implementing UHC is making sure all stakeholders practice good stewardship in ensuring the integrity of their health claims.

If all accredited health providers know that PhilHeath has a strong, fraud-proof PMC system that will certainly catch deceitful health care scalawags, that is the most effective deterrent that can reduce, if not stop, the draining of limited health care resources.

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