Philippine Journal of Surgical Specialties Vol. 79, No. 1, January-June 2024, pp 20-28

Comparison of PhilHealth Case Rate and Actual Charge of Hospitalization for Common In-Patient Surgical Procedures from 2017-2019 in a Level 3 Hospital

Author(s): Liza Margarita B. Ilagan, MD; Ramoncito C. Magnaye, MD, MHA, FPCS, FPSGS; Clarence Pio Rey C. Yacapin, MD, FPCS, FPSGS; Aldrin B. Cuasay, MD, FPCS, FPSGS and Amabelle A. Moreno, MD, FPCS, FPSPS

To compare PhilHealth case rate versus actual charge of hospitalization of common general surgery procedures in a Level 3 government hospital from 2017-2019.

The five most common procedures were determined and records were reviewed. Hospital bills and professional fees (PF) were compared to the PhilHealth rates using t-test. The range of perceived acceptable PF was determined by an online survey

The most common procedures were open appendectomy, open cholecystectomy, initial repair of inguinal hernia, total thyroidectomy and modified radical mastectomy. The study included 1934 charts. For service cases, the hospital bill for appendectomy was significantly lower than the PhilHealth institutional fee, while the rest were significantly higher. For private cases, hospital bills for open cholecystectomy and modified radical mastectomy were significantly higher, while that of open appendectomy was lower. The average PF of private patients in all procedures were significantly higher than the PhilHealth rate, also reflected on the survey.

The significant discrepancies between the actual charges and the PhilHealth case rates showed that the PhilHealth rates were insufficient for the five most common general surgery procedures in a Level 3 government hospital.

Key words: Universal Health Care Act, PhilHealth case rate, Philippines, insurance