PD First Z Benefit Package: Light at the End of the Tunnel

NEVER mind if she had to do the exchange in the midst of discussions on PhilHealth benefits for members undergoing peritoneal dialysis (PD). Monien Bangcas simply had to let her voice be heard. After all, she is a concerned stakeholder having been on dialysis for the last nine years.

I met up with Bangcas and other patients and family members of PD patients recently to seek their insights on the upcoming launch of a special benefit package for peritoneal dialysis. The discussion focused on the merits of having a package especially developed for PD patients whose need for at least four exchanges everyday is well underscored. With Bangcas were Max Tabangcura, himself on PD for three years now; Fe Espique whose husband is also on PD; Raquel de Guzman whose daughter Marquel has been on PD for five years; Cris Crisostomo whose sibling is on PD for two years; Boyet Esteban and Fernando Gumabao. All of them were eager to share their insights with hopes of making the package more responsive to the needs of PD patients, especially for the long-term.
ESRD in the Philippines
The incidence of end-stage renal disease in the Philippines is at 120 per million population and the most common causes of ESRD among Filipinos are diabetes, hypertension and chronic glomerulonephritis. In PD, a patient makes use of his own body tissues inside the abdominal cavity as a filter to remove excess water and waste products from the body. The procedure is a lifetime exercise, or at best, for as long as resources are available to enable the patient to undertake the daily exchanges.
While some patients proceed to hemodialysis right after having been diagnosed with ESRD, some opt for PD for various reasons. "Sa hemodialysis, nagcocollapse yung veins ko, at lagi akong nae-emergency," said Bangcas who shifted to PD after a year and one month on hemodialysis. She was quick to add, however, that "mas magastos ang peritoneal dahil aside sa dialysis, meron pa kaming binibiling mga gasa, ointment, alcohol, tape every week for dressing" and that if infection sets in, "merong culture na pinapagawa at madaming antibiotics na iinumin."In countries like Thailand, PD is being advocated as the first option for the treatment and management of ESRD. Studies have shown that patients on PD have exhibited improved survival rates and reduced morbidity, and that PD helps reduce infection-related complications. It also allows for a flexible schedule for the patient, affords the patient the convenience of home therapy, and results to better patient satisfaction.
Z Benefit Package for PD
In line with efforts to strengthen PD first as the initial line of treatment for Filipinos with ESRD requiring renal replacement therapy, PhilHealth is enabling PD patients to see the light at the end of the proverbial tunnel by developing and introducing the PD First Z Benefit Package. It is the fruit of extensive research and wide-ranging consultation with patients, patient support groups, nephrologists, the Philippine Society of Nephrologists (PSN), providers of PD care, the Department of Health – NCPAM, BLHD, NCHFD, and the Philippine Charity Sweepstakes Office (PCSO), balanced with sound actuarial analysis to ensure availability of the package for the long haul. “There is general support for a PD First policy and this is the direction of government,” said Santillan.
Earlier, PD is being paid at a case rate amount of P4,000.00 per session. Through the PD First Z Benefits, however, PhilHealth aims to provide total coverage for renal replacement therapy to help improve the quality of life of diagnosed ESRD patients in the country.
When told that the package is worth P270,000 annually, Bangcas and the other interviewees were happy that the amount is higher by at least 35 percent of what they are usually able to avail themselves of from PhilHealth. They were, however, concerned about whether or not the package is available for only one year, raising feelings of uncertainty on their coverage for the following year. The package is available year after year, for as long as the PD patient-member is able to satisfy the selections criteria and has been pre-authorized for entitlement to the package, also on a yearly basis.
Pre-authorization and selections criteria
To qualify for the PD First Z benefit, a patient has to be pre-authorized by PhilHealth based on a selections criteria that include having a permanent Tenckhoff PD catheter in the abdominal cavity, must have completed PD initiation at an accredited health care institution, with stable vital signs and adequately trained to perform PD at home using manual exchanges. The patient must also be at least ten (10) years of age, has no history of cancer, must be HIV-negative, must have no mental incapacity that would interfere with the patient’s ability to comply with the PD prescription, and no severe illnesses, among others.
Package inclusions
The PD First Package is inclusive of PD solutions and accessories. The number of exchanges ranges from 90 to 120 bags per month based on the PD prescription, and includes from 90 to 120 caps per month, according to the number of prescribed monthly exchanges. It also covers for the professional fee of attending physician with whom the PD patient must consult with every month. “Sana i-cover din ng package yung mga laboratory exams na kailangang i-undergo ng pasyente every month,” appealed Espique, adding that these diagnostic laboratory examinations cost them about P6,000 monthly. Dr. Melanie Santillan, Head of PhilHealth’s Product Team for Special Benefits however, said that PhilHealth cannot possibly cover for everything that a PD patient needs, and understandably so since PhilHealth also has to balance its package with the actuarial feasibility of maintaining this for the long-term.
As for the group’s call for PhilHealth to include a cycler in the package once a year, Santillan said that it cannot be made part of the package yet since the PD solution, which is a 5.0 liter bag, is not yet approved by the Food and Drug Administration. Besides, she stressed, “the package is intended for manual PD exchanges which is the minimum standard even in other models like Thailand, Hongkong, and Canada,” adding that should the patients opt for the automated PD exchanges, they can do so but the patients will have to shoulder the additional cost.
Patients enrolled in the PD First Z Benefits shall be deducted not more than five (5) days from the 45 days annual benefit limit, regardless of the actual number of PD exchanges in a calendar year.
No balance billing
Under the PD First Z Package, Indigent and Sponsored members, including the kasambahays, are entitled to the No Balance Billing Policy while a fixed co-pay not exceeding 11 percent of the entire package cost has been negotiated with PD First providers for PhilHealth members from other member-categories. With the NBB, patients need not pay anything to the provider, in excess of what the PhilHealth package covers.
On the other hand, the fixed co-pay sets a maximum amount of payment that a provider may charge a patient vis-a-vis the member’s PhilHealth benefit. "Okey sa amin yung 11 percent na co-pay," Bangcas said, in behalf of the group, adding that they used to shell out about 14 percent of P180,000 a year for their other needs.
The National Kidney and Transplant Institute (NKTI) shall be the reference health care institution for the PD First Z Benefits, while PhilHealth is in talks with other HCIs such as Philippine General Hospital, Quirino Memorial Medical Center, Rizal Medical Center, Tondo Medical Center, Las Piñas Satellite and General Hospital and Amang Rodriguez Medical Center for these to become contracted facilities for the package.
Joining forces for PD
The interviewees, who have banded together to form the Peritoneal Dialysis Society of the Philippines (PDSP), also welcomed the idea of home visits by PD providers. "It will lessen our risk of infection," they said, and will enable the providers to really check on whether or not the PD exchange is being done according to the standards of care. The home visits will also enable PhilHealth to ensure that the solutions being provided to the patient are not being sold to some other individual.
Tabangcura, Bangcas, Esteban and the other interviewees have started the PDSP with hopes of reaching out to other PD patients who do not know where to seek help, "para may malalapitan sila," they said. They also want to help educate PD patients who are not yet aware of the advantages of going into PD, and how this procedure can actually enable the patient to live his life as normally as possible. "Kung maayos ang PD procedure, mas improved ang quality of life,"said Tabangcura.
It is also their shared goal to rally resources for the benefit of its members. "Kung halimbawa limang bags ng solutions ang magagamit niya, ang ibabalik niya sa organisasyon ay anim na bags para mas marami ang makinabang," mused Tabangcura. He also added that part of PDSP’s advocacy is to have counselling, aside from material and moral support, since they recognize that PD patients have to cope with depression and frustration.
They also envision the group to be making a headway as far as following up on the claims for reimbursements of its members with PhilHealth is concerned. Today, these patients file their claims directly with PhilHealth and they rely heavily on these reimbursements to finance their next cycle of exchanges. With the PD First Package, the PD provider shall ensure that all services and supplies are given to the patient and PhilHealth shall reimburse the provider for the said services and supplies. This will be less worrisome for the patient, whose constant worry is resource generation, aside from infection that may occur along the way.
Life's lessons
When asked what are the most important lessons they are learning as they journey through life with PD, the interviewees had various thoughts: “to stay positive,” “importance of family,” “kapit at tiwala lang sa Diyos,” “mahabang pasensya,” and “huwag paghinaan ng loob.” Espique stressed that “mas lalo dapat iexpress ang iyong pagmamahal” noting that a PD patient and the family becomes closer and that they can also serve as models to other families with PD patients.
Note to PhilHealth
As the meeting wrapped up, the group expressed hopes that they could take a quick look at the draft issuance introducing the PD First Z Benefits so that they can provide additional inputs “hindi para sa amin kundi pang-long term sana at para sa iba pang PD patients,” said Bangcas. The sentiment was also echoed by Gumabao:“sana bago ilabas ang circular magkaroon ng audience para all is well,” he said. The package is effective after publication for all approved pre-authorizations starting July 30, 2014.
They also thanked PhilHealth “sa walang sawang pagtulong sa pasyente” and looked forward to the implementation of the PD First Z Benefits soon “para makabalik na ako sa work na walang aalalahanin” said Crisostomo who had to give up work at the pier to help raise funds for the PD exchanges of his sibling.“Sana tuloy-tuloy na ang Z package para sa PD,” echoed de Guzman, a single parent who takes pride in the fact that her daughter is a very cooperative patient. They also hoped that medical professionals, especially those involved in renal replacement therapy, will support the implementation of the new Z benefit package, and suggested that PhilHealth work closely with other government institutions such as the PCSO to streamline complementing resources for the everyday PD patient.
Indeed, there is light at the end of the tunnel. For these PD patients whose voices have been heard loud and clear, the PD First Z Benefit Package may just be the answer to their prayers. (Maria Sophia B. Varlez)