Patient-level experience of health care financing

@#The patient-level experience of health care financing in the Philippines is complex and challenging. While almost all citizens of the Philippines are now covered by the Philippine Health Insurance Corporation (PhilHealth), in practice, not all health care expenses are covered during an episode of illness. Consequently, individuals facing illness might be compelled to seek alternative financial sources to pay for health care costs. This can result in high out-of-pocket (OOP) expenses for patients, which can be financially devastating, especially for those who are already struggling to make ends meet.1 In 2022, government schemes and compulsory contributory health care financing schemes accounted for 44.8% of the Philippines’ current health expenditure, while household OOP payments contributed a close 44.7%.2 Multiple studies evaluating PhilHealth coverage have highlighted the insufficiency of case rates to meet the complete cost of hospitalization.3 4 5 6 This is especially true for high-cost procedures and treatments. As a result, patients with large hospital bills may be left with a significant financial burden, even after they have received PhilHealth reimbursement. Beyond the OOP costs that admitted patients are required to settle, which are reflected in the hospital bill after applying discounts, PhilHealth coverage, and other financial aid, patients often incur additional health care expenses that are not included in the bill. These non-billed OOP costs can encompass a variety of expenses, such as those for medications and diagnostics that are not available in the hospital, and for living allowances, transportation fees, and salaries of private duty nurses, caregivers, and/or patient watchers. These costs are typically borne by the patients themselves and are not usually reimbursed by insurance or the hospital. To cope with these expenses, many patients seek financial aid from various government schemes designed to provide medical assistance. These include programs—such as the Malasakit Program7 and the Medical Assistance for Indigent Patients program8—and the services offered by medical social workers. However, these schemes often do not cover everything in the excess bill, and the distance between offices, coupled with extended waiting times, could discourage patients from pursuing financial aid. Moreover, the paperwork required for PhilHealth coverage and government assistance, especially for patients from outside the city, who must travel home to get the necessary documents, poses significant challenges. Despite seeking financial help, many patients continue to grapple with OOP expenses due to insufficient assistance. This can lead to financial hardship, debt, and even bankruptcy. In some cases, it can also push patients into poverty. In addition to the challenges of inadequate PhilHealth coverage and limited financial assistance, there is also the question of cost efficiency in health care delivery and the reasonableness of professional fees. Are the diagnostics requested really warranted? Is there judicious use of therapeutics? Are the professional fees fair and proportionate to the health care services provided, taking into account the complexity of the case, the time spent, the risks involved, the physician’s professional standing, and the patient’s financial capacity?9 Unwarranted or unjustified use of diagnostics and therapeutics, and disproportionate professional fees, increase health care spending and ultimately put the financial burden on patients. In practice, while the PhilHealth Z Benefit Packages do outline a list of acceptable diagnostic and therapeutic interventions, as well as professional fees for specific packages,10 11 12 much of the practice of determining diagnostics, therapeutics, and professional charges in health care is largely left to the discretion of the health care providers. There are a number of things that can be done to improve the patient-level experience of health care financing in the Philippines. First, there needs to be more research on the adequacy of PhilHealth case rates. These studies will help improve the financial protection that PhilHealth provides to patients. Second, interventions in clinical practice should be aimed at optimizing patient diagnostic and therapeutic management. These measures can both improve patient outcomes and reduce health care costs. Third, professional fees should be efficiently managed to ensure that they are balanced and equitable. A comprehensive and thoughtful approach to fee management can foster transparency in health care spending and greater public trust in the health care system. Fourth, the government should implement mechanisms to address the barriers in availing PhilHealth and other financial assistance schemes. These mechanisms should make it easier for patients to access the funds they need to pay for their health care. One such mechanism is the Malasakit Centers Act,7 13 which encourages public hospitals to establish one-stop shops within their premises, where patients and their families can seek medical assistance from various agencies. This law should be efficiently enforced, as it simplifies the process of obtaining medical assistance. Future interventions should be geared towards reducing OOP expenses. This can be done by making the diagnostic and therapeutic management of patients cost-efficient, ensuring that professional fees are justifiable, expanding the coverage of PhilHealth, and making it easier for patients to access affordable health care services. While PhilHealth and other government schemes have made strides towards universal health coverage, significant gaps in practice still exist. These need to be addressed in order to improve the experiences of patients procuring health care services and make health care truly universal and accessible to all.

Rizal D. Aportadera formula versus Parkland formula in the fluid resuscitation of patients with burn injuries: Cohort study

Background@#Fluid management is crucial during the first 24 hours after a burn injury due to different systemic responses of the body@*Objective@#To compare the outcomes of patients with partial- or full-thickness burns initially managed using the Parkland (PRK) formula with those initially managed using the Rizal D. Aportadera (RDA) formula, a fluid resuscitation formula with added sodium bicarbonate. @*Design@#Cohort study. @*Participants@#181 male and female patients, aged 7 months to 78 years, with partial- or full-thickness burns. @*Setting@#RDA Burn Unit of Southern Philippines Medical Center, Davao City, from January 2008 to December 2018. @*Main outcome measures@#Proportions of patients with prolonged hospital stay, sepsis, and death; odds ratio of having the outcomes for selected factors. @*Main results@#Of the 126 males and 55 females, with overall mean age 25.70 ± 20.92 years, included in this study, 175 (96.69%) had partial-thickness burns and 6 (3.31%) had full-thickness burns. Among the patients, 108/181; 59.67% were managed with the PRK formula, while 73/181 (40.33%) were managed with the RDA formula during fluid resuscitation. Compared to the PRK group, the RDA group had significantly lower mean length of hospital stay (11.67 ± 9.69 days vs 17.22 ± 20.45 days; p=0.0317) and lower proportion of patients with prolonged hospital stay (2/73, 2.74% vs 13/108, 12.04%; p=0.0287). Full-thickness burns had independent association with prolonged hospital stay, while major burns had independent association with death. @*Conclusion@#Compared to patients in the PRK group, those in the RDA group had significantly shorter hospital stay. Full-thickness burns and major burns were independently associated with prolonged hospital stay and death, respectively.

The importance of considering ethics in research

@#Research—or the production of new knowledge—needs to be done ethically. Why is it important to factor ethics into the practice of producing new knowledge? The word “ethics” refers to “moral principles that govern a person’s behavior or the conducting of an activity.”1 Moral principles are “principles of right and wrong that are accepted by an individual or a social group.”2 If we add “research” into the term “ethics,” the phrase “research ethics” would now refer to the principles of right and wrong that govern a researcher’s behavior or the conducting of research. “Research ethics” is the principles of right and wrong in action, in practice, or in the actual implementation of knowledge production. When we conduct human research, we produce new knowledge, often with development goals in mind, for instance—to be more efficient in work, to make clients more satisfied, to diagnose more accurately, to treat more effectively, to prevent illness, to predict outcomes, or to save lives. We ask questions and answer them to produce new knowledge, which we hope will eventually inform the actions that we take in order to meet our development goals. This is a very human pattern of behavior: question-answer-knowledge-action, to strive towards development. It is human nature to work towards development—towards making existence a better experience. This is the reason why we have the propensity to marvel and to introspect, and then to question and look for answers to our questions. This is the most fundamental reason for generating more and more knowledge, for doing research. And this is good—the intention is noble because it benefits us, the people around us, and even those who will exist after us. Generating new knowledge is a conscious effort to do something that gives benefit to oneself and to others. The problem with knowledge production is that it can cause harm, especially to research participants. Harm within the context of research can either be physical, psychological, economic, sociocultural, or legal. Many researches in the past have caused direct, indirect, intentional, or unintentional harm to the participants, or even to the public.3 Asking questions, collecting and analyzing data to answer these questions, and communicating findings and interpretations to others all involve harm. That is why we have international and national guidelines, state laws, and research implementation standards that support human protection systems in research. In the Philippines, many mandates pertaining to health research order the establishment of research ethics committees, the review of all researches involving humans or human data by these committees, and the accreditation of these committees by the Philippine Health Research Ethics Board, the policy-making body in health research ethics in the country.4 These mandates should guide academic and health institutions, as well as agencies that conduct researches involving humans or human data, in providing human protection in research. Deciding to do research is an ethical act. If we decide to pursue knowledge, we affirm and celebrate the human features of introspection, examination of our actions, and pursuit of excellence in the things we do as a society. Actually doing research—i.e., asking questions, recruiting participants, giving interventions, gathering and analyzing data, to reporting findings—offers several opportunities for more ethical acts because, when we perform the tasks involved in research, we are presented with opportunities to do good for others, to prevent harm from coming their way, to show respect for and to acknowledge others as fellow humans, to actively participate in restoring or maintaining justice, and to practice professionalism, honesty, and integrity. By properly applying ethical principles in doing research, and by ensuring that a system for the oversight and guidance of research implementation is in place, we can prevent harm, minimize the risk of harm, and avoid misconduct in research. From there on, we can pursue the ethical act of doing research and positively gain from seizing the opportunities that the act offers. That is why it is important to factor ethics into the practice of producing new knowledge.

Mandates pertaining to the ethical review of researches involving humans, and the establishment and accreditation of research ethics committees

@#In 2003, the secretaries of the Department of Health (DOH) and the Department of Science and Technology (DOST) signed a memorandum of understanding to institutionalize the Philippine National Health Research System (PNHRS) for the management of research in the country.1 One of the groups constituted under the PNHRS was the Technical Working Group (TWG) on Ethics, which created strategies that highlight the role of ethics in a responsible health research system. Among the recommendations of the Ethics TWG was the establishment of the Philippine Health Research Ethics Board (PHREB).2 In 2006, the PHREB was formally created through DOST Special Order 2006-91 “to ensure that all phases of health research shall adhere to universal ethical principles that value the protection and promotion of the dignity of health research participants.” Since then, PHREB has become the country’s policy making body on health research ethics.2 3 In 2013, the Republic Act 10532一or the PNHRS Law一was enacted.4 The Act strengthened the mandate of PHREB to ensure protection of the welfare, rights, and safety of human research participants, and the implementing rules and regulations (IRR) of the Act specified the policies that facilitate the achievement of the PHREB mandate.5 In 2017, through DOST Special Order 2017-248, DOST established research ethics monitoring boards (REMBs) in Region I, Region VI, and Region XI to assist in the comprehensive and consistent implementation of PHREB policies at the regional level.6 The creation of PHREB in 2006 initiated several other mandates from PHREB and other agencies that implement the PNHRS. These mandates一shown in the infographic一support human research participant protection through ethical reviews of research protocols, establishment of research ethics committees, and maintenance of quality standards of these committees through accreditation. Many of these mandates are national in scope, but a few are specific to Davao Region (Region XI).

Implementing research ethics

@#In this epoch of progress in health care, when systematic generation of knowledge is considered the cornerstone of health development, there is increasing focus on the need to demonstrate the ethicalness of doing research. Stories of harm inflicted on research participants and scientific misconduct in research are rife in the history of science, even within our immediate past.1 The lessons that we have learned from these stories have shaped the ethical research guidelines that we abide by and uphold today.2 3 Within the last 15 years, since the creation of the Philippine Health Research Ethics Board (PHREB) as the country's policy-making body on research ethics, numerous mandates have been issued to ensure human research participant protection and research integrity. Taken together, these mandates push for the ethical review of researches that are proposed to be done among humans or to use human data, the establishment of research ethics committees (RECs) in institutions that produce these researches, and the maintenance of quality standards in the operation of these RECs through accreditation by the PHREB.4 The enactment of Republic Act No. 10532 in 2013, formally institutionalized the Philippine National Health Research System and tied up all these mandates that pertain to research ethics.5 In effect, all institutions that generate human research一hospitals, health facilities, pharmaceutical companies, government and private agencies, universities, colleges, and even high schools一are expected to comply with these mandates. Many institutions that produce research involving humans or human data find it very challenging to set up a series of procedures for the review of these researches. For one, submitting research protocols一after they have gone through several revisions as directed by the technical research committee or panel一to a second committee for ethics review, approval, and implementation monitoring is a relatively new practice. The extra layer of scrutiny, the intellectual disagreements of technical committees and RECs, and the additional time and effort it takes to get an REC approval all figure in the arguments of those who are against the ethics review process. Research offices or training committees may have to put a system in place to incentivize submission or discourage non-submission of research protocols for ethics review. All in all, it takes administrative political will to incorporate a procedural pathway to ethics review into the usual research generation procedures of an institution. The institutions can arrange a mechanism for external ethics committees or, more commonly一and indeed more efficiently一they can create their own in-house RECs. The demands related to the establishment and operation of in-house RECs constitute an altogether different set of challenges for the institution. REC members and staff will have to be trained to competently do ethics reviews and perform administrative tasks within the REC office. There is also the difficulty of coming up with a good roster of trained reviewers who can dedicate time for committee work. The institution will also have to allocate physical space, and finance both the cost of REC operations and the remuneration of office personnel. The REC accreditation process is meant to reduce variation of procedures and maintain the quality of operations by way of recommending certain standards in the structures, processes, and outputs of RECs. On the part of PHREB as the accrediting body, the process requires careful organization of a well-trained accreditation team that can efficiently and scrupulously evaluate the REC operations and produce helpful recommendations. The process is inherently challenging for REC managers as well since, most of the time, it requires meticulous (re)engineering of REC operations. Above all these demands in complying with the mandates on research ethics is the pervasive call for us to generate trustworthy research results in ways that are beneficial and non-harmful to humans. An ethically produced piece of knowledge is a valuable contribution to scientific progress.

COVID-19 research agenda for health care services

@#Due to the long quarantine, with several levels of intensity and degrees of implementation, we all have, more or less, similar experiences with the COVID-19 pandemic. Starting early this year, we stayed home for a long time, we had ourselves tested, our friends or relatives had themselves tested, and some of us may even have tested positive for the infection. We listened to, or read, or watched the news, about the statistics of COVID-19 morbidity and mortality, lockdowns, reopenings, resurgence and reinfections. And then, we received all sorts of information—true, fake, inaccurate, anecdotal—and some were derived from systematically produced knowledge, i.e., properly conducted research or ongoing research.

Ideas for post-quarantine health care services in Southern Philippines Medical Center

@#The response of Southern Philippines Medical Center (SPMC), the largest tertiary government hospital in Davao Region, to the coronavirus disease 2019 (COVID-19) pandemic is detailed in the brief report of Astudillo.1 The guiding principles for implementing the structural and operational modifications made by SPMC in its health care services during quarantine were: to focus on the diagnostic and therapeutic management of patients with probable or confirmed COVID-19 and to limit the spread of SARS-CoV-2, the virus that causes COVID-19. As can be gleaned from the hospital's census before and during quarantine, extreme focus on COVID-19 health care, when sustained for a long time, can potentially compromise other essential, but non-COVID-19, health care services. On the other hand, restoring full-scale health care services to pre-COVID-19 amplitude can potentially increase the spread of the virus. Restoring hospital health care delivery to a more balanced state—comprehensive in scope, yet fully responsive to the epidemiological status of COVID-19—requires several rigorous cycles of planning, execution, and revision. Fortunately, the quarantine period has given SPMC—as a health care provider—an opportunity to maximize the efficiency of the delivery and utilization of health care services amid the extreme focus on infection control and management. It also compelled the institution to more frequently carry out certain procedures that were not often practiced before—teleconferencing, teleconsultations, operating on skeleton workforce, allowing work from home schemes, etc. As SPMC prepares to gradually reinstate health care services that were scaled down or put on hold during the quarantine period, some practices that need to be developed or sustained in the presence of the ongoing COVID-19 pandemic are worth pointing out for consideration. Like SPMC, hospitals that provide diagnostic and therapeutic managements of patients with COVID-19 are considered COVID-19 hotspots—where concentrations of patients with the disease are very high, and where most hospital staff who eventually get infected with SARS-CoV-2 have been initially exposed to the virus. Therefore, the goal of health care from this point on is to keep people away from hospitals that manage patients with COVID-19, as much as possible. Any task, transaction, operation, or essential person-to-person interaction that is not dependent on hospital facilities and equipment should be done outside the hospital.

Adequacy of PhilHealth case rate coverage for pneumonia among children under 5 years old admitted in a government hospital: Policy notes

@#Thirty-seven Filipino children die of pneumonia daily, and 90% of those who die are under 5 years old.1 More than 50% of childhood pneumonia is readily treatable with antibiotics; however, only 31% of children with pneumonia receive the antibiotics they need.2 From 2016 to 2018, pneumonia and acute lower respiratory tract infection (ALRTI) comprised the 3rd leading cause of morbidity in the Philippines across all age groups. In 2018, there were 213,611 reported cases of pneumonia and ALRTI among Filipino children <5 years old.3 In 2011, the Philippine Health Insurance Corporation (PhilHealth) created case rate packages for selected medical procedures and medical conditions, including pneumonia. A case rate is a fixed amount that PhilHealth pays to a health care provider for the diagnostic and therapeutic care of a patient with a particular disease or condition. The case rates for moderate-risk and high-risk pneumonia are PHP 15,000 and PHP 32,000, respectively.4 PhilHealth also introduced a no-balance-billing (NBB) policy, applicable to all PhilHealth Sponsored Program members and/or their dependents when they seek health care in a government hospital for diseases or conditions included in the case rate packages. The policy provides that government hospitals shall not charge other fees or expenses beyond the case rate to patients covered by the policy.4 Given the high incidence of pediatric community-acquired pneumonia (PCAP), policies that support current efforts in attaining adequate financial protection of patients--or their families--would certainly improve health outcomes related to the disease. The aim of this article is to recommend health policies based on the results of a study on health insurance coverage of patients with PCAP.

Experiences of child sexual abuse clients in a Women and Children Protection Unit: Policy notes

@#A survey done by the World Health Organization in 2014 revealed that only less than 10% of the survivors of child sexual abuse (CSA) received any service—whether it be health, psychosocial, police, or legal.1 In Kenya and Haiti, only 13.4% of the girls and only 7% of the boys who experienced sexual abuse received health services, while in Swaziland, 24% of clients received health services.1 2 3 In several countries, one-stop centers were established to provide legal, medical and psychosocial services for survivors of child sexual abuse and violence in one location. These centers spare clients from visiting multiple institutions to seek help and from the trauma of retelling their personal ordeal to various individuals many times over.4 Psychosocial support is given by a social worker who assesses the client on the first interview. If the social worker detects any signs of abuse, the client is then escorted to an adjacent room where a child-friendly police officer would take care of the legal aspects of the case. A medical doctor performs a thorough physical examination in a separate room. Further special diagnostics and treatment are provided by the center. The staff of the centers must also have undergone appropriate training on the medicolegal aspects of handling clients who come to the center.5 In the Philippines, the establishment, operation, and maintenance of a Women and Children Protection Unit (WCPU) was based on the Administrative Order 1-B s. 1997 of the Department of Health (DOH)6 and the Republic Act 9262 Anti-Violence Against Women and their Children (VAWC) Act of 2004 and its implementing rules and regulations.7 In 2008, the DOH then developed a set of standards for the structures and processes of WCPUs in the country.8

Psychosocial factors related to postmastectomy pain syndrome among women with breast cancer: Cross-sectional study

Background@#An insight on the association of psychosocial factors with postmastectomy pain syndrome (PMPS) can help in the holistic management of patients with PMPS. @*Objective@#To determine the proportion of patients with PMPS among those who underwent mastectomy for breast cancer and identify factors associated with the syndrome. @*Design@#Cross-sectional study. @*Setting@#Outpatient Unit in Southern Philippines Medical Center. @*Participants@#45 women who had mastectomy for breast cancer. @*Main outcome measures@#Proportion of patients with PMPS; prevalence odds ratios (POR) of having PMPS for selected factors. @*Main results@#The patients had a mean age of 53.18 ± 8.09 years, mean BMI of 23.57 ± 2.65, and--on average--were 27.09 ± 35.76 months postmastectomy upon entry into the study. Of the 45 patients, 22 (48.89%) had PMPS. Univariate POR of having PMPS were significantly high for patients who: had distant metastasis (POR=5.56; 95% CI 1.27 to 24.29; p=0.0227), experienced premastectomy breast pain (POR=35.70; 95% CI 6.14 to 207.52; p<0.0001), were in late-stage family life cycle (POR=9.18; 95% CI 1.02 to 82.22; p=0.0476), and were in late-stage family illness trajectory (POR=4.96; 95% CI 1.39 to 17.70; p=0.0137). @*Conclusion@#In this study, 48.89% of patients had PMPS. Factors associated with PMPS include: having distant metastases, having premastectomy breast pain, being in late-stage family life cycle, and being in late-stage family illness trajectory.

Wishlist for the efficient implementation of service delivery networks

@#In the Philippines, the concept of a local network of facility-based services, coordinated to efficiently implement health care programs, has been encouraged in the past. In 2008, through an administrative order to address maternal and neonatal health risks, the Department of Health (DOH) Secretary stipulated that the “DOH shall advocate and promote the standards of a stable and mature service delivery network to local stakeholders.”1 The implementing rules and regulations of Republic Act 10354, or the Responsible Parenthood and Reproductive Health Act (RPRH) Act of 2012, defined specific standards for facilities within a service delivery network (SDN) to support reproductive health care.

Introducing: Slices

@#Medical journals are meant to both reflect the science behind medical practice and facilitate the advancement of the discipline.1 They present newly generated knowledge in the field, with the general aim of improving health care. The effectiveness of a journal article to convey its messages can potentially affect the development of health care. Medical information from journals used to be designed for medical practitioners alone. Now, increasingly, publishers feel the need to package the same information to make it accessible to different types of readers. Almost always, readers go to journals to look for evidence that can support decisions about health. The common questions readers ask when looking for evidence in medical literature have something to do with incidence or prevalence of conditions, effectiveness of therapy or prevention, accuracy of diagnostic approaches, and associations of exposures and outcomes.