Seniors hit by the suspension of cataract surgery payments by PhilHealth

A senior citizens group has denounced the decision of Philippine Health Insurance Corp’s (PhilHealth) unilateral decision to withhold payment for ophthalmologists and eye clinics that perform free cataract surgery for seniors in the Philippines.

Philhealth has made the decision to suspend the payment for the operations on cataract causing blindness on account of alleged irregularities. In response, senior citizens groups said that such a decision is tantamount to letting hundreds of thousands of Filipinos go blind. Various groups have expressed their disappointment towards this decision.

With several stakeholders displeased by the suspension, Philhealth now faces scrutiny from various groups.

Why did Philhealth stop the free cataract surgery for seniors?

PhilHealth suspended the payment for the operations on account of fraudulent behavior and unethical marketing activities. However, many argue that the institution’s suspension of cataract surgery payments was done by Philhealth despite the absence of proof and an absolute disregard for due process.

Raymond Evangelista, Quezon City Eye Center (QCEC) founder and CEO, said in a statement issued last July 2:

“We firmly believe that several actions of PhilHealth against us are unjust and laden with prejudice […] Pending the completion of their audit and investigation, we have been forced to close down indefinitely.”

Testifying at the Senate on Wednesday, PhilHealth President Alexander A. Padilla said syndicates at the QCEC led to the P2-billion PhilHealth claims for cataract operations in 2014. He said clients had to undergo a cataract operation that is often not needed. Padilla added that he had suspended payments to QCEC and the Pacific Eye Institute that he accused of engaging in what he called a “racket.”

The free cataract surgery operations have long been beneficial to PhilHealth members, specifically those who are underprivileged or tenants of nursing homes for the elderly.

Evangelista responded to this claim by saying that they are not “seeking” patients as Padilla alleged.

“Seeking patients is a detestable, unethical and illegal practice where doctors solicit patients who do not observe certain procedures for profiteering purposes.”

He also denied the center is engaged “in any illegal marketing activity and any attempt to prove otherwise is futile because it simply isn’t true.”

How does the suspension of free cataract surgery for the poor and senior citizens affect the Philippines?

Hernan Nicdao, legal counsel of the Senior Citizens party-list group, said that senior citizens will be the most impacted sector should PhilHealth pursue its suspension of payments to eye clinics and doctors because government health facilities do not have the capability to serve the needs of cataract sufferers nor the doctors to perform such highly specialized procedures.

Nicdao said government facilities alone could not accommodate the number of people seeking cataract operations, and that private eye clinics are the ones that have taken up the slack, operating on PhilHealth members for free in exchange for PhilHealth reimbursement. Of course, private clinics are known to be exponentially more expensive. Even with possible free insurance for senior citizens, the costs could still be high without the benefits from Philhealth.

“Now, PhilHealth is saying that it will not pay private eye clinics because of alleged irregularities. I think the real irregularity is PhilHealth’s cruel decision to leave cataract patients in the dark, with nowhere to go.”

“All of these simply because PhilHealth, in my opinion, is suffering financially and did not expect that there will be a groundswell of cataract patients demanding free operations,” he said.

PhilHealth’s website shows that it has more than 86.2 million members, and more than half, or 43.7 million, are indigents. There are also more than 4 million senior citizens and dependents and lifetime members, among others. As PhilHealth members, these individuals are all entitled to free cataract surgeries.

In response to the suspension of cataract Philhealth surgeries…

Hernan Nicdao, legal counsel of the Senior Citizens party-list group, said senior citizens and all members of PhilHealth in good standing have the right to avail themselves of the free cataract operations offered by private eye clinics since these are benefits that come with membership in PhilHealth.

“PhilHealth’s decision to stop processing payments to eye clinics for cataract operations that have been performed due to alleged irregularities is very suspicious and is very detrimental especially to senior citizens, many of whom suffer from cataract,” he said. “I think the real reason for PhilHealth’s refusal to pay the eye clinics is that it is running out of funds.”

Nicdao said PhilHealth’s “Bulag na Daan” policy must be fully investigated by Congress because it will lead to more blindness in the country. He said authorities must also look into PhilHealth’s finances to determine its ability to pay for the free cataract surgery of senior citizens and its more than 86 million members.

“What is the actuarial life of PhilHealth at present? Did it conduct a study on the financial impact of the claims from its tens of millions of members? Is PhilHealth being mismanaged and are the so-called padded billings accusing the eye clinics of actually committing the works of people inside the agency?” he asked.

The Department of Health (DOH) has said that cataract is the top cause of blindness in the Philippines and that there are more than 400,000, mostly poor Filipinos, who have cataract. It would seem that Philhealth’s decision to suspend their payment to private clinics is a direct opposition to the fact that DOH enhances eye care.

Continuing free cataract operations for senior citizens

“PhilHealth should not stop the free cataract surgeries, and must pay the doctors and clinics that have performed such operations. In the first place, PhilHealth accredited these clinics and doctors, and gave clearance to every cataract patient that underwent the procedures in these clinics,” Nicdao added.

Just last September, the DOH said it was pushing for a package with PhilHealth to provide free cataract surgery to poor Filipinos.

“PhilHealth is trying to evade its responsibility; it has taken the bulag na daan [blind path] and is merely using the supposed irregularities in some eye clinics as smokescreen,” Nicdao added.

With minimal evidence found, many senior citizen groups are clamoring for the suspension of the decision.