Syndicated Cataract Surgery in the Philippines

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In the Philippines, cataract removal ranked 4th among the top procedures that the Philippines Health Insurance Corporation (PhilHealth) paid for in 2014. PhilHealth’s mandate is to provide health insurance coverage and ensure affordable, acceptable, available and accessible healthcare services for all citizens of the Philippines. Expenditure was equivalent to P3.7B ($81.95M) out of P78B ($1.73B) total benefit payments.

A recent finding reported in MANILA by PhilHealth had at least 6 health care facilities that conducted cataract surgeries on patient members without their consent. The alleged syndicated practices claimed bigger benefit payments for cataract removal procedures. The Philippine Senate along with PhilHealth is therefore investigating at least 10 ambulatory surgical centers claiming for cataract procedures discovered to have “very conspicuous rise” in claims in 2014, that also coincided with complaints from patients.

In an impoverished 3rd world country like the Philippines with over 100 million inhabitants constituting 1.38% of the world’s population, majority have limited access to basic needs, let alone healthcare services. The government and church are enmeshed in each other’s business and the few educated elite dominate the society. Healthcare is a privilege and people are beset with diseases and sufferings secondary to overpopulation and pollution such as malnourishment, communicable diseases and others. As such, wrongdoings that defraud the already deprived system have tremendous impact to the society’s well-being and to the generations that will follow. The Department of Health, the local Ophthalmological Society, individual health practitioners and the community all play a role in ensuring honest and equity access to healthcare services including cataract surgeries that contribute to improvement of quality of life. Necessary policies should be in place to protect the Philippine constituents of their healthcare privileges, the PhilHealth system so it can continue with its mandate and the healthcare practitioners.

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5 Responses to “Syndicated Cataract Surgery in the Philippines”

  1. robindross Says:

    Cataract surgery and uncorrected refractive error are the two major causes of global blindness affecting working age adults worldwide. There is a growing burden of preventable blindness on the poor, with a higher incidence in women. For many, cataract surgery can be miraculous and life changing.

    The ethics of informed consent whether in research, clinical care or global health cannot be eschewed in the name of “benefit to the poor”. Here, it appears that the Philipines health insurer, PhilHealth, offered fair financial renumeration to the cataract surgeons who performed surgery and it is extremely distressing that these cases were performed without permission.

    It would be interesting to study what these patients believed was going on with their vision and why they were being evaluated in the first place before cataract surgery was performed without consent.

    A 2008 PhilHealth document at www/philhealth.gov/circulars/2009/circ16_2009.pdf revealed that cataract surgery package was paid at a rate of 16,000 pesos with a split of 8000 pesos for the operating room and hospital charge and 8000 pesos for the surgeon. Whether one or both eyes were performed paid the same rate of 16,000 pesos. However, if more than 48 hours passed between eyes, the rate became 16,000 per eye.

    Most interesting was the exclusion of fees for consultation and testing. My guess is patients who sought cataract surgery would believe these to be inclusive.

    Again proper informed consent also includes articulate discussion with patients regarding any financial responsibilities or alternatives should they wish to proceed with a surgical procedure. In global health, we are often performing surveys, studies, procedures, and often bridging cultural and language barriers so this report indicated financial conflict of interest clouding ethical judgment.

  2. cgoh2 Says:

    Most cataracts are associated with aging and cataract surgery is one therapeutic options when the vision is significantly affected. The aforementioned case is a serious public health implication as the silver tsunamis hits every country.

    In this case, the governmental body such as the Department of Health who oversees the health services and policy maker of the country will be important to be involved to investigate the cause of this allegation. Whilst influential, it is the local Ophthalmological Society or perhaps the individual health practitioners who will be important collaborative stakeholders and could provide the professional and scientific expertise whether such cataract surgery has indeed been unethically carried out. They form the professional board who can censure any unethical professionals of their practicing liccences. An equally important stakeholder will be the department of justice and enforcement department who will be able to provide the enforcement and legal support to prosecute any wrongdoers while providing fairness and justice during any legal proceedings.

    Of course the community is an important stakeholder who often provides the initial tip-off and assist the relevant authorities identify such wrongdoing and correct any misdoings.

    Noting that Roman Catholicism forms the predominant religion in the Philippines, the influence and impact of the church can be very important in the everyday of life for every citizen. It is likely that any policy changes and implementing of campaign towards unethical syndicated cataract surgery can be better effected through the religious support in this cultural setting.

  3. sterlingharing Says:

    This is definitely an important issue; health services research worldwide grapples with the intersection of care and finance. In this case, it appears that the financial incentives offered for services have overcome the better judgement and ethical obligations of a few providers, leaving the patients subject to invasive procedures that they may not want or need.

    You’re right in pointing out that a key to the solution of this problem is going to be oversight. As long as financial incentives go unchecked, there will always be a minority of providers who seek profit over patient safety.

    One thing I might suggest here is offering a very direct “ask” of your audience. Perhaps name a specific law or proposition, and ask your readers to support it.

  4. kerryescott Says:

    The performance of unnecessary cataract surgeries, and without patient consent, is a very serious issue, which highlights the vulnerability of the poor within private insurance-based health systems.

    I see many parallels between this issue in the Philippines and the hysterectomy scandal in rural areas of India, where I work. Over the past five years it has been well documented that many rural women are incorrectly told that they require hysterectomies by private hospitals. Many of these women are insured by a government health insurance program, launched in 2008, that enables people below the poverty line to claim coverage for surgeries up to Rs. 30,000 (US $540). The private hospitals are able to access the insurance reimbursement for this surgery, so they push women to have hysterectomies. (http://www.bbc.com/news/magazine-21297606)

    Both of these cases illustrate the need for strong public monitoring systems, whereby the rates of various procedures are scrutinized and compared with expected norms. When reimbursement for higher-than-expected rates of cataract surgery are identified (or hysterectomy, caesarean sections, etc.) investigation is vital. The rise in insurance coverage for the poor increases the perverse incentives for surgeons—and heightens the need for oversight.

    Medical practitioners and the public (particularly the poor) have an enormous asymmetry of information about the necessity of surgical procedures. It is up to the government to ensure that a robust medical regulatory body ensures doctors do not abuse their considerable power.

  5. hlian Says:

    I have been drawn to this blog post as such over-utilization of medicine is also very common in China where I work. Given the information asymmetry in healthcare, patients rely on doctors to make decisions even when the proper information is being communicated, not to mention if the doctors fail to disclose the necessary information.

    From the China experience, there are limited options to prevent such unnecessary cataract surgeries when it seems it is the norm. The starting point is probably set up a few gold standard centers where the government, despite its limited capability to regulate a large number of facilities, can focus on and exert the necessary control and guidance. Those excellence of care centers will probably be flooded by patients, but at least there will be a few trustworthy healthcare options for the general public.

    Similar to some of my classmates have indicated above, I would have preferred to see this blog point out what are the specific actions that can be taken to tackle the presented public health challenge, particularly given the cultural background in Philippines.

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