PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 1 January – June 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 1 January – June 2020

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ORIGINAL ARTICLES

ABSTRACT
Objective: To determine the effectiveness of the Philippine Health Insurance Corporation
(PhilHealth) case rate system in reducing out-of-pocket expenses among non-no balance billing
(NBB) patients undergoing thyroidectomy under the Department of Otorhinolaryngology –
Head and Neck Surgery of the Baguio General Hospital and Medical Center from February to
September 2018.

Methods:
Design: Prospective Cross- Sectional
Setting: Tertiary Government Hospital
Participants: Sixty-four (64) randomly selected patients with PhilHealth who

underwent thyroidectomy who agreed to participate and reveal their statements of accounts

Results: Among the study population, 20% belonged to the no balance billing (NBB) category,
with zero out-of-pocket expenses during their confinement. Eighty percent (80%) belonged
to the non-NBB category and also incurred zero hospital charges. In addition, there was no
significant difference in the individual categories of the hospital expenses between the two
groups except for the surgical procedures (p= .018, 95% CI). The accumulated total expenses
also did not significantly differ between the two groups (p= .063, 95% CI). The minimum amount
billed was PhP 1,984.95, while the maximum amount charged was PhP 38,898.65, with a median
of PhP 18,703.28 and interquartile range of PhP 4,251.78 (X

U
: PhP 20,848.74, X

L
: PhP 16,596.96).

There were no reported out-of-pocket expenses from non-NBB patients. The actual cost of
thyroidectomy did not differ significantly from the case rate provided by PhilHealth among all
the RVS categories.

Conclusion: The PhilHealth case rate system is effective in reducing out-of-pocket expenses
among non-NBB patients who underwent thyroidectomy in our institution during the study
period.

Keywords: out-of-pocket expenses; thyroidectomy; health care financing; health expenditures:
universal health coverage

Effectiveness of the Philippine Health Insurance
Corporation Case Rate System for Thyroidectomy

in a Tertiary Government Hospital

Josephine Ann P. Ramos, MD
Frederick Mars B. Untalan, MD

Department of Otorhinolaryngology
Head and Neck Surgery
Baguio General Hospital and Medical Center

Correspondence: Dr. Frederick Mars B. Untalan
Department of Otorhinolaryngology
Head and Neck Surgery
Baguio General Hospital and Medical Center
1 Governor Pack road, Baguio City, Benguet 2600
Philippines
Phone: (+63) 9175066551
E-mail: tongmd@yahoo.com

The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere in full or in
part, in print or electronic media; that the requirements for
authorship have been met by all the authors, and that each
author believes that the manuscript represents honest work.

Disclosures: The authors signed a disclosure that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional
affiliations that might lead to a conflict of interest.

Presented at the Philippine Society of Otolaryngology Head
and Neck Surgery Descriptive Research Contest (2nd Place).
December 6, 2019. Palawan Ballroom, Edsa Shangri La Hotel,
Mandaluyong City.

Philipp J Otolaryngol Head Neck Surg 2020; 35 (1): 51-55 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International

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The creation of the Philippine Health Agenda in 2016 has re-
emphasized the need for accessible health care through a universal
health insurance.1 The Philippine Health Insurance Corporation
(PhilHealth) was seen as the gateway to free affordable care using
No Balance Billing (NBB) for the poor or basic accommodation and
fixed co- payment for non- basic accommodation.2 The NBB policy
provides that no other fees or expenses shall be charged or paid for
by indigent patients above and beyond the packaged rates during
their confinement period.3 The limited depth and breadth of coverage,
however, has resulted in high levels of out-of-pocket payments, which
continue to rise despite the enormous programmatic and policy
reforms in the health financing system.

This problem has been observed in our local setting. Among
the 600 patients who underwent surgery in the Department of
Otorhinolaryngology- Head and Neck Surgery during the previous year,
a significant percentage of non-NBB patients was noted to have large
out-of-pocket expenses for a myriad of reasons. These unnecessary
expenses can be highly catastrophic and impoverishing. Patients were
noted to have a higher risk to forgo care, delay health seeking and
become non- compliant.

This study aims to determine the effectiveness of the PhilHealth
case rate system in reducing out-of-pocket expenses among non-
NBB patients undergoing thyroidectomy. This may be used to create
a standardized process by which hospital charges can be based.
Once standardized, process defects, as well as processing time will be
reduced. Policies can be created to reduce out-of-pocket expenses
to rational levels. Strategies may be identified to expand PhilHealth
benefits to cover a broader range of services. These can help make
health care more equitable, inclusive, transparent and accountable in
line with the Philippine Health Agenda for 2016- 2022.

METHODS
This is a prospective cross-sectional study carried out in a tertiary

public hospital. The population was composed of the statements of
accounts of public (charity) patients who underwent thyroidectomy
from February to September 2018.

The charts of patients that were included in the study must have
fulfilled the following criteria: (1) must have PhilHealth listed as the
health insurance; (2) must indicate that the patient underwent any of
the following types of thyroidectomy: (a) partial thyroid lobectomy,
unilateral, with or without isthmusectomy (RVS: 60210), (b) partial
thyroid lobectomy, unilateral, with contralateral subtotal lobectomy,
including isthmusectomy (RVS:60212), (c) total thyroid lobectomy,
unilateral, with or without isthmusectomy (RVS: 60220), (d) total

thyroid lobectomy, unilateral, with contralateral subtotal lobectomy,
including isthmusectomy (RVS: 60225), (e) thyroidectomy, total or
complete (RVS: 60240), (f ) thyroidectomy, removal of all remaining
thyroid tissue following previous removal of thyroid (RVS: 60260) or
(g) thyroidectomy, total or subtotal for malignancy, with limited neck
dissection (RVS: 60252). The following exclusion criteria were applied:
(1) use of other health insurances aside from PhilHealth; (2) presence of
other co-morbid conditions in the final diagnosis; (3) more complicated
types of thyroidectomy, including the following: (a) thyroidectomy,
total or subtotal for malignancy, with radical neck dissection (RVS:
60254), (b) thyroidectomy, including substernal thyroid gland; sternal
split or transthoracic approach (RVS: 60270) or (c) thyroidectomy,
including substernal thyroid gland; cervical approach (RVS: 60271); and
(4) incomplete charts.

We limited the study to 64 billing statements which was computed
using the prevalence of patients that underwent thyroidectomy for the
year 2016 (N=76), a confidence interval of 95%, a margin of error of 5%
and a power of 80%. The billing statements were selected using a table
of random numbers.

After obtaining approval from the Institutional Technical Review
Board and Research Ethics Committee, informed consent was obtained
from the participants. Upon admission, data such as employment
(unemployed/ contractual/ self- employed/ employed), salary in
Philippine Pesos (PhP) per month (no fixed income/ less than PhP
10,000/ PhP 10,000 - 19,999, PhP 20,000 – 29,999, PhP 30,000 and
above), PhilHealth membership classification (employed/ individually
paying/ overseas Filipino worker/ sponsored/ indigent/ lifetime/ senior
citizen) and billing classification (NBB/ non-NBB), were obtained using
a questionnaire. On the day of the patient’s discharge, the procedure
performed (i.e., type of thyroidectomy) and statement of account were
obtained, including particular expenses (room and board, drugs and
medicine, supplies, radiology, laboratory and ancillary procedures, use
of the operating room, and surgical procedures) and any out- of- pocket
payments.

Descriptive statistics were calculated including the comparison of
the cost of hospitalization and the PhilHealth case rate. Descriptive
summary measures for continuous variables were presented in terms of
mean ± standard deviation or median and interquartile ranges; and for
categorical variables, summaries were presented in frequency counts
and proportions. Comparisons between the cost of hospitalization
among NBB and non-NBB patients and associations of the items
included in the PhilHealth case rate and actual cost of thyroidectomy
utilized the independent t-test. All data were encoded in Microsoft
Excel for Mac 2011 Version 14.4.0 (Microsoft Corporation, Redmond,

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PhiliPPine Journal of otolaryngology-head and neck Surgery 5352 PhiliPPine Journal of otolaryngology-head and neck Surgery

ORIGINAL ARTICLES

WA, USA). Statistical analysis was performed using IBM SPSS Statistics
for Windows Version 20.0 (IBM Corp., Armonk, NY, USA). All hypotheses
tests used a 0.05 α- level of significance.

RESULTS
A total of 64 patients met the inclusion criteria and consented

to participate in the study. The profile of the participants based on
the employment status, monthly income, PhilHealth membership
classification, billing classification and procedure performed is
presented in Table 1.

The comparison of the average cost of hospitalization between NBB
and non-NBB patients indicate that there was no significant difference
in the individual categories of hospital expenses, except for the surgical
procedures (p= .018, 95% CI). The accumulated total expenses also did
not differ significantly between the two groups (p= .063, 95% CI) as
shown below in Table 2.

The minimum amount billed was PhP 1,984.95 while the maximum
amount charged was PhP 38,898.65 with a median of PhP 18,703.28
and interquartile range of PhP 4,251.78 (X

U
: PhP 20,848.74, X

L
: PhP

16,596.96). There were no reported out-of-pocket expenses from non-
NBB patients.

The comparison of the average actual cost of thyroidectomy and
the PhilHealth case rate is also shown in Table 3.

Based on the average cost of thyroidectomy procedures, RVS
60225 (total thyroid lobectomy, unilateral, with contralateral subtotal
lobectomy including isthmusectomy) had the highest average cost
at PhP 21,556.30 while RVS 60220 (total thyroid lobectomy, unilateral,
with or without isthmusectomy) had the lowest value at PhP 16,282.12.
The actual cost of thyroidectomy did not differ significantly from the
case rate provided by PhilHealth among all the RVS categories.

DISCUSSION
The Philippine Health Agenda was launched to achieve universal

health care for all Filipinos through the achievement of three health
system goals.1 Among these, financial risk protection through the
national health insurance program (NHIP) is PhilHealth’s primary
responsibility.4 This aims to protect Filipinos especially the marginally
poor against the catastrophic cost of illness. Through the NHIP,
resources need to be generated to improve the provision of public
health services to consequently achieve the Millennium Development
Goals.5

Health insurance coverage is measured at the individual level to
include both public insurance (though PhilHealth) and private insurance

Table 1. Clinico- demographic profile of patients who underwent thyroidectomy at the Baguio
General Hospital and Medical Center from February to September 2018

EMPLOYMENT

FREQUENCY PROPORTION (%)

Unemployed
Contractual
Self- Employed
Employed

No Fixed Income
< PHP10,000
PHP 10,000 - 19,999
PHP 20,000 – 29,999
≥PHP 30,000

Employed
Individually Paying
OFW
Sponsored
Indigent
Lifetime
Senior Citizen

NBB
Non- NBB

RVS 60210
Partial Thyroid Lobectomy, Unilateral,
with or without Isthmusectomy
RVS:60212
Partial Thyroid Lobectomy,
Unilateral, with contralateral subtotal
lobectomy, Including Isthmusectomy
RVS: 60220
Total Thyroid Lobectomy, Unilateral,
with or without isthmusectomy
RVS: 60225
Total Thyroid Lobectomy, Unilateral,
with contralateral subtotal
lobectomy, Including Isthmusectomy
RVS: 60240
Thyroidectomy, Total or Complete
RVS: 60260
Thyroidectomy, Removal of all
Remaining Thyroid Tissue following
previous removal of thyroid
RVS: 60252
Thyroidectomy, Total or Subtotal
for Malignancy, with Limited Neck
Dissection

35
0

25
4

31
11
20
2
0

7
35
0
2

13
0
7

13
51

54.7
00.0
39.1
06.3

48.4
17.2
31.3
03.1
00.0

10.9
54.7
00.0
03.1
20.3
00.0
10.9

20.3
79.7

06.3

00.0

21.9

03.1

39.1

21.9

07.8

=64

PROCEDURE PERFORMED

BILLING CLASSIFICATION

PHILHEALTH MEMBERSHIP CLASSIFICATION

MONTHLY SALARY

=64 =100

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be charged or be paid for by indigent patients above and beyond the
packaged rates during their confinement period.3

Among the patients who underwent thyroidectomy from February
to September 2018, 20% belonged to the NBB category with zero
out-of-pocket expenses during their confinement. Eighty percent
(80%) belonged to the non- NBB category which also incurred zero
hospital charges. The average cost of hospitalization did not differ
significantly between the NBB and non- NBB patients. This, however,
seems to contradict the fact that patients still complain of the
high cost of out-of-pocket expenses in the outpatient department
especially for laboratories, clearances and medications prior to their
surgery. The compensation provided for by the PhilHealth case rate
for thyroidectomy covers only the expenses during the patient’s
confinement. It excludes those incurred during the patient’s consult in
the outpatient department. The current setup for patients scheduled
for thyroidectomy is to perform all diagnostic workups on an out-
patient basis. These include but are not limited to neck ultrasound,
thyroid function tests (FT4, TSH), fine needle aspiration biopsy (FNAB),
complete blood count (CBC), urinalysis (UA), 12-lead electroardiogram
(ECG) and chest x-ray. Should there be any derangement in the patient’s
laboratory results that would warrant treatment, the patients are
prescribed medications and are advised to have their laboratory tests
repeated at the out-patient department (OPD) on follow- up. A patient
who needs to undergo treatment for abnormalities in thyroid function
(i.e., hyperthyroidism or hypothyroidism) for instance, would need to
take medications daily for 2-6 weeks before a repeat laboratory testing
could be done. Such expenditures were therefore not considered “out-
of-pocket expenses” in this study since they were incurred prior to the
patient’s confinement.

Despite a uniform case rate for simple thyroidectomy cases, there
exists a wide standard deviation in the hospital bill charged ranging
from PhP 1, 984.95 to PhP 38, 898.65. Variations in charges commonly
came from procedures, drugs and medicine, and operating room
supplies like oxygen, which could be caused by the lack of a uniform
system of charging in the materials used. Each particular expenditure
category (i.e., room and board, drugs and medicines, supplies,
radiology, laboratory and ancillary procedures, use of the operating
room, and surgical procedures) could not be compared to a standard,
since the given PhilHealth case rate does not include a breakdown of
its coverage. Nevertheless, the case rate provided by PhilHealth for all
RVS cases used in this study is effective in terms of reducing the out-of-
pocket expenses among non-NBB patients during their confinement.

Our study limitations include design bias, since it did not account
for all of the expenses incurred for thyroidectomy particularly the
out-of-pocket expenses in the out- patient department. The lack of a

Table 2. Comparison of the average cost of hospitalization between NBB and non-NBB patients
undergoing thyroidectomy

PARTICULARS
NBB in PhP

(N=51)
NON-NBB

in PhP (N=13) P-VALUE

Professional Fee

Surgical Procedures

Use of Operating Room

Radiology, Laboratory
and Other Ancillary
Procedures/ Clinical
Laboratory Expenses

Medical Supplies

Drugs and Medicine

Room and Board

ACCUMULATED
TOTAL EXPENSES

0.00

2,576.63

4,569.23

786.08

1,522.83

2,002.74

1,879.69

13,337.20

.000

.018

.415

.434

.165

.113

.169

.063

0.00

2,176.97

4,661.96

545.76

1,273.73

2,138.92

1,769.23

12,556.57

Table 3. Comparison of the actual cost of thyroidectomy and PhilHealth case rate

AVERAGE ACTUAL COST
OF THYROIDECTOMY

(PhP)
CASE RATE

FROM PHIC (PhP) P-VALUE

RVS 60210*

RVS 60220+

RVS 60225≠

RVS 60240§

RVS 60260¶

RVS 60252#

31,000.00

.210

.212

.208

.210

.203

.209

18,660.85

16,282.12

21,556.30

19,857.07

21,200.26

20,800.98

*Partial thyroid lobectomy, unilateral, with or without isthmusectomy.
+Total thyroid lobectomy, unilateral, with or without isthmusectomy.
≠Total thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy.
§Thyroidectomy, total or complete.
¶Thyroidectomy, removal of all remaining thyroid tissue following previous removal of thyroid.
#Thyroidectomy, total or subtotal for malignancy, with limited neck dissection.

(through private health maintenance organizations (HMOs).6 Out-of-
pocket health expenditure is defined as direct purchases by households
of health services or goods, like medicines, hospital room charges,
consultation fees and diagnostic tests. It excludes dental charges,
food supplements, various alternative therapies and transportation
for medical care.6 Purchasing of health services is particularly relevant
in the thrust of financial risk protection.5 The focus of social health
insurance in the Philippines has long been on expanding membership,
but as coverage approached 80-90 percent of the population, this has
shifted to increasing the reimbursement rate (or the so-called “support
value”). Through this, health insurance indeed reduced a household’s
probability of falling into poverty due to a member’s illness.7 Along with
the introduction of case payment is the introduction of the No Balance
Billing (NBB) policy, which provides that no other fees or expenses shall

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ACKNOWLEDGEMENTS
We would like to thank Dr. Mary Jane T. Lubos for her supervision in editing the manuscript, and

Mr. Emmanuel J. Bacud for his assistance in statistical analysis.

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5. Picazo OF, Ulep VGT, Pantig IM, Ho BL. A Critical Analysis of Purchasing of Health Services in the
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standard by which expenditure categories could be compared to also
pose another limitation. It is therefore our recommendation to include
all outpatient expenses in the case rate coverage to reduce the out-
of-pocket expenditures further. There should also be a standardized
system of charging of supplies used to maximize the case rate, probably
through the use of OR packages for thyroidectomy. Further studies are
also encouraged to determine if the PhilHealth case rate is effective for
private patients undergoing thyroidectomy and for other conditions or
procedures.

In conclusion, the PhilHealth case rate system is effective in reducing
out-of-pocket expenses among non-NBB patients who underwent
thyroidectomy in our institution from February to September 2018.