UHC is a daunting challenge if PhilHealth itself is not reformed. Policy reform has moved ahead of systems reform. Health insurance is essentially about systems: membership eligibility, provider accreditation, provider payment, and quality assurance.
As a long-term observer of PhilHealth, let me offer these points to reform the social health insurance (SHI) program.
The ongoing policy reforms are in the right direction, although still incomplete. I disagree with the call to suspend the implementation of the new universal health care (UHC) law. In fact, the problems merely point for the need to expedite implementation of it. UHC is a daunting challenge if PhilHealth itself is not reformed. We should view the (inadvertent) PHIC revamp as a blessing in disguise, for it offers the once-in-a-lifetime opportunity to clean up the institution.
There are many well-meaning people in PhilHealth, but there are obvious problems of organizational development. PhilHealth’s problems are largely organizational and management in nature. The institution is "balkanized" into turfs and it would take an iron fist to fix it.
Policy reform has moved ahead of systems reform. Health insurance is essentially about systems: membership eligibility, provider accreditation, provider payment, and quality assurance. Integrity must be the operative principle in each of these systems. Computerization is necessary, but although the computers and software are there, they are not integrated. There may be inherent "ïncentive problems" (an obvious euphemism) why systems integration has not happened.
PHIC staff found in cahoots with corrupt providers must be charged. Ditto with providers. Ghost patients, upcoding, unnecessary confinements, and similar practices must be flagged timely, and culprits heavily penalized, dis-accredited, and jailed.
The latest PhilHealth scandal highlights the need for an SHI Watchdog. This should be an independent institution (NGO) with mandate to examine key PhilHealth operations on a regular basis. The watchdog culture should not be punitive but rather facilitative: to analyze data, to correct mistakes, and to offer feasible solutions. At present, even with FOI, it is extremely difficult to get data from PHIC, even for a legitimate research project.
The medical and allied professions should wake up to the reality of corruption in their ranks. The Duterte administration ought to appeal to their better nature. The licensing (PRC) and accrediting agencies and professional societies should also stand ready to expel members who commit fraud.