UNDER THE MICROSCOPE

PhilHealth Circular No. 2024-0014 on the Institutionalization of 156 Hemodialysis (HD) sessions  and Coverage Expansion issued on July 1, 2024,  also effective same date, mandates that all chronic kidney disease (CKD) patients can avail of HD at any government or private institution at no extra cost to the patient, called No Balance Billing (NBB).

The package rate per session is ₱4,000 inclusive of professional fees with minimum standards of hemodialysis package and certain laboratory exams. Thus, the effective rate per session is ₱3,650 for the dialysis facility.

This is indeed a boon for CKD patients, who no longer have to struggle with trying to pay for twice- or tri-weekly dialysis to cleanse their blood of waste products that normal kidneys  could otherwise filter and excrete in the urine. The main beneficiaries are indigent patients, who can ill afford the costs of dialysis.

However, we should also take a look at the other side of the equation—hemodialysis centers, laboratories and nephrologists who cater to the needs of CKD patients. We need to consider all the elements specified in the circular that will impact viability and continuity of operations for the HD centers. 

The circular specifies that laboratories need to re-cost their laboratory test rates for the exams needed by CKD patients. Per our calculations, laboratories stand to lose around ₱85,000 a year per patient alone with the new scheme. Multiply that with the number of CKD patients it caters to and it will balloon to an astronomical amount.

While the circular advises  labs to get together to purchase reagents in bulk to avail of lower costs, it is simply not practical, considering different labs employ different brands of equipment, for which their reagents are dedicated to perform within acceptable limits. These equipment items are on a reagent tie-up basis, so the labs have no choice but to procure their supplies from the distributors of the machines.

Even government hospitals will have difficulty in doing common procurement with their individual procurement offices operating per institution’s guidelines, which are strictly overseen by the Commission on Audit (COA). Government hospitals are also mandated to earn from their operations, so the circular runs counter to this mandate. 

As for private dialysis facilities, the costs of drugs, medicines, laboratory tests and supplies are much higher than those of government facilities. Remember too that the circular covers only the basic items and not those that have to be administered to an individual patient. With the NBB, patients will object to any and all charges even not covered by the circular, presenting complications for the HD facilities. The Private Hospitals Association of the Philippines Inc. (PHAPI) is now trying to deal with the fallout of the circular and how to comply without bankrupting their hospitals. Several private hospitals in the Visayas area have written PHAPI president Dr. Jose Rene de Grano about these matters, fearing for the survival of HD centers across the country.

The Philippine Society of Nephrology Inc. (PSNI) has also petitioned PhilHealth president and CEO Emmanuel Ledesma on concerns over the circular. They raise several issues that may result in undesirable patient outcomes, citing the lack of or unclear guidelines for alkaline phosphatase which is not actually part of the overall CKD patient assessment. It also excluded Blood Urea Nitrogen (BUN) which is essential.

PSNI also cites the standardization of medicines when doses should be individualized to prevent over- and under-dosing.

Further, they raise the issue of the number of dialyzers included in the package. Dialyzers are reprocessed and reused due to their cost, but the reuse varies from patient to patient. HIV patients, for one, cannot reuse dialyzers as a minimum standard of care.

Additional costs for medicines and diagnostic tests during emergency conditions are not covered by the circular. Such medicines are essential to address complications of dialysis such as  chest pain, fever, chills, syncope and sudden respiratory or cardiac failure. Will patients expect the HD center to shoulder such costs?

Private facilities often customize their services with highly specialized single dialysis machines in private rooms with dedicated private nurses. But the circular prohibits additional billings even under such circumstances.

Clearly, there is no one-size-fits-all solution to a complex issue. But putting a Maximum Drug Retail Price (MDRP) on dialyzers, erythropoeitin and related big-ticket items can bring some relief to HD centers. Tests that can be dispensed with are the lipid profile and anti-HBs, which do not contribute to CKD patient evaluation.

At the end of the day, we need to find a balance between affordability for CKD patients and the sustainability of HD centers, whether they be private or government. Eventually, the CKD patients will suffer the consequences should the HD centers shut down for lack of viability.