Republic of the Philippines
House of Representatives
Quezon City

Eighteenth Congress
First Regular Session

House Bill Wo. 2197

Introduced by Representatives
Estrellita B, Suansing and Horacio P. Suansing, Jr.

LANATORY NOTE

Kidney diseases, including chronic kidney disease and end stage renal
disease, consistently rank among the top 10 causes of morbidity (7) and
mortality (8) in the Philippines.’ Many Filipinos damage their kidneys as a
result of various risk factors, among these are poor diet, unhealthy lifestyle
and complications of poorly managed chronic illnesses such as diabetes and
hypertension. The damage to the kidneys is irreversible, hence, treatment
options such as peritoneal dialysis, hemodialysis, and kidney transplants
become inevitable.

‘The 2017 Philippine Renal Disease Registry annual report shows that
21,535 Filipinos underwent dialysis due to kidney failure in 2016; this data
does not include those who are unable to get treatment due to prohibitive
costs or inaccessibility to treatment centers. The cost of one dialysis session
ranges from P2,800 to P4,000 per session.? While PhilHealth expanded its
coverage for hemodialysis from 45 to 90 sessions per year for its members, it
is not enough, especially for those who need to have at least two (2) dialysis
sessions per week.

This bill seeks to provide a comprehensive Renal Replacement Therapy
for patients with end stage renal disease in national, regional, and provincial
government hospitals by including it in the coverage of treatment services
provided by the PhilHealth.

Among the key provisions of this bill include the establishment of renal
replacement therapy facilities in national, regional and provincial government
hospitals, establishment of the Chronic Kidney Disease Prevention and Health
Promotion for the benefit of patients of end stage renal disease and their
relatives, expansion of the PhilHealth benefit package for kidney
transplantation from living donors, mandatory reporting of private and public

+ philippine Statistics Authority
2 Philippine Daily Inquirer 28 May 2019


hospitals, as well as dialysis centers and transplant facilities, to the Philippine
Renal Disease Registry, increasing the PhilHealth Z-benefit package rates for
peritoneal dialysis and hemodialysis and directing the Philippine Charity
Sweepstakes Office to provide for the remaining sessions needed by the
patient for peritoneal dialysis or hemodialysis exceeding the number of
sessions provided in the PhilHealth package, free dialysis treatment for
indigent patients while promoting peritoneal dialysis as the first option to
attain adequate dialysis, provide training for medical and non-medical
practitioners directly involved in the care of patients with end stage renal
disease and undergoing peritoneal dialysis and hemodialysis, establishment
of a Chronic Kidney Disease Counseling Clinic, and the creation of a Renal
Disease Control Program.

This bill is a re-file of House Bill No. 9156, which was approved by the
House of Representatives on Third and Final Reading during the 17%
Congress. In view of the foregoing, immediate passage of this bill is earnestly
sought.

REP. LITA B. SUANSING REP. HORAI P. SUANSING, JR.
1% District, Nueva Ecija 24 District, Sultan Kudarat


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Republic of the Philippines
House of Representatives
Quezon City

Eighteenth Congress
First Regular Session

~- 0197
House Bill No.

Introduced by Representatives
Estrellita B. Suansing and Horacio P. Suansing, Jr.

AN ACT
PROVIDING A COMPREHENSIVE RENAL REPLACEMENT THERAPY (RRT)
FOR PATIENTS WITH END STAGE RENAL DISEASE IN NATIONAL,
REGIONAL, AND PROVINCIAL GOVERNMENT HOSPITALS, INCREASING
THE PHILHEALTH PACKAGE RATE FOR RENAL REPLACEMENT
THERAPY OF MEMBERS, AND APPROPRIATING FUNDS THEREFOR

Be it enacted by the Senate and the House of Representatives of the Philippines
in Congress assembled:

SECTION 1. Short Title. - This Act shall be known as the “Comprehensive
Renal Replacement Therapy Act.”

SEC. 2. Declaration of Policy. - It is a declared policy of the State to adopt
an integrated and comprehensive approach to health development that wil
provide Comprehensive Renal Replacement Therapy (RRT) to improve the
delivery of health care services to patients diagnosed with End Stage Renal
Disease (ESRD), and to encourage them to have a kidney transplant, primarily
within the first two (2) years of starting dialysis.

‘The State shall endeavor to make essential goods, health and other
social services available to all the people at affordable cost. There shall be
priority for the needs of the of the underprivileged sick, elderly, disabled,
women and children. The State endeavor to provide free medical care to
paupers.

It is also hereby declared as a policy of the State to improve the delivery
of health care services to the people and to ensure hospital facilities are
available, affordable and accessible to the people.

SEC. 3. Definition of Terms. - As used in this Act:


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(a) Dialysis facility refers to a health facility that provides treatment
for ESRD to indigent patients and disseminates information on the various
forms of RRT such as kidney transplantation, peritoneal dialysis and
hemodialysis;

(b) End Stage Renal Disease (ESRD) refers to the final stage of chronic
kidney disease in which the kidneys no longer function well enough to meet
the needs of daily life;

(©) Hemodialysis (HD) refers to a medical procedure to remove fluid
and waste products from the blood and to correct electrolyte imbalances. This
is accomplished using a synthetic membrane or dialyzer which is also referred
to as an “artificial kidney”;

(4) Indigent refers to a patient who has no source of income or whose
income is not sufficient for family subsistence as identified by the Department
of Social Welfare and Development (DSWD) through the National Household
Targeting System (NHTS) for Poverty Reduction, or those patients who are
indigents but are not listed in the NHTS as assessed by the municipal social
development officer;

(e) Kidney transplant (KT) refers to a surgical procedure to place a
kidney from a live or deceased donor into a person whose kidneys no longer
function sufficiently to sustain the person’s life;

() National, Regional and Provincial hospitals refer to hospitals and
stand-alone dialysis facilities operated and maintained either partially or
wholly by the national, regional and provincial government or other political
subdivisions, or any department, division, board or other agency thereof;

(@ No Balance Billing refers to the government policy of not charging
the medical expenses incurred over and beyond the PhilHealth package rates
to a PhilHealth member who has undergone medical treatment;

(h) Peritoneal dialysis (PD) refers to a treatment for kidney failure and
a type of dialysis that uses the person’s peritoneum (lining of abdominal
cavity) as the membrane through which fluid and toxic substances are
exchanged with blood;

(i) PD First Policy refers to the policy where peritoneal dialysis, when
feasible, is offered as the first dialysis modality to RRT patients;

() Renal replacement therapy (RRT) refers to therapy that partially
replaces the functions of the normal kidney. This may be in the form of kidney
transplantation, peritoneal dialysis and hemodialysis.


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SEC. 4. Establishment of Dialysis Services Wards or Units in National,
Regional, Provincial Government Hospitals. - Within five (5) years from
the effectivity of this Act, all national, regional, and provincial government
hospitals, including all stand-alone dialysis facilities are hereby required to
establish, operate and maintain a dialysis service facility in their hospital,
including both peritoneal dialysis and hemodialysis. The same hospitals and
dialysis facilities should also be mandated to train nephrologists, dialysis
nurses, dialysis technicians, and operating room nurses’ in both peritoneal
dialysis and hemodialysis.

All national, regional, and provincial government hospitals, including
stand-alone dialysis facilities shall have a dialysis service area compliant with
the licensing and accreditation requirements imposed by the Department of
Health (DOH) and Philippine Health Insurance Corporation (PhilHealth),
respectively, for private dialysis clinics. It shall further be provided with the
necessary personnel and equipped with complete dialysis equipment and
supplies for both hemodialysis and peritoneal dialysis, as required by the
DOH and the PhilHealth from private dialysis clinics.

All patients diagnosed with ESRD must be referred to a DOH-accredited
transplant facility to attend a pre-transplant orientation and to be counseled
on the advantages of undergoing transplantation as the best treatment for
kidney failure. They will undergo medical evaluation for suitability for
transplantation. For those found medically suitable for transplantation, all
potential organ donors of the patient shall be evaluated to determine
compatibility and medical suitability. If no living donors are available, then
the patient will be enrolled in the deceased organ donor waiting list. This will
ensure that all patients with ESRD are offered the option of kidney
transplantation.

SEC. 5. Chronic Kidney Disease (CKD) Prevention and Health Promotion.
~All national, regional and provincial government hospitals, and stand-alone
dialysis facilities should establish CKD prevention strategies and health
promotion activities which include: advocacy activities targeting relatives of
dialysis patients who are at high risk for developing CKD themselves, the
provision of instructional materials and regular educational activities on the
common symptoms of kidney disease such as its risk factors, healthy diet and
lifestyle, common tests to diagnose kidney disease, the most common causes
of kidney failure, and advisories on the appropriate protocols for the
diagnostic evaluation of possible kidney disease.

Patients and their relatives should be informed about the availability of
the proper medicines from government health centers such as those for
diabetes and hypertension, and the importance of the regular intake of
medicines and monitoring of kidney function through regular laboratory
testing and regular clinic follow-up with a qualified physician. All activities

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pertaining to the aforementioned programs should be documented
accordingly.

SEC. 6. Quality Standards of Dialysis Services and Transplant
Facilities. - Hospitals, dialysis centers for both hemodialysis and peritoneal
dialysis, and transplant facilities shall comply with the safety and quality
standards of dialysis or transplant services which shall be strictly monitored
by the PhilHealth and the Health Facilities and Services Regulatory Bureau of
the DOH.

SEC. 7. Philippine Renal Disease Registry. - Private and public hospitals,
dialysis centers for both hemodialysis and peritoneal dialysis, and transplant
facilities shall be mandated to report to the Philippine Renal Disease Registry
of the DOH the incidence and prevalence of patients receiving peritoneal
dialysis or hemodialysis treatment, and who have received a kidney
transplant as a requirement for the renewal of their respective DOH licenses
to operate a dialysis center or transplant facility Registration of all dialysis
patients in the PhilHealth dialysis database will be required prior to the
availment of benefits for both peritoneal dialysis and hemodialysis.

SEC. 8. PhilHealth Benefit for Kidney Transplantation. — The PhilHealth
benefit for kidney transplantation from living donors shall be expanded
accordingly. This shall include the cost of laboratory work-up for both
recipient and donor candidate, hospitalization for the transplant operation
including induction immunosuppression and maintenance oral
immunosuppression, machine perfusion of procured organs, the cost for
organ retrieval, all medications required during the hospital stay, as well as
post discharge laboratories up to 1 month for the recipient, and up to 1 year
for the donor.

The cost for organ retrieval and machine perfusion will be established
by the DOH-Philippine Organ Donation Program for all organ procurement
organizations.

‘The PhilHealth benefit package for kidney transplantation shall cover
the evaluation and screening of the kidney donor and recipient up to the
transplant procedure and post-transplantation procedures and remedies.
This is inclusive of both pre- and post-kidney transplantation measures for
the benefit of End Stage Renal Disease patients.

In order to support kidney transplantation as the best treatment option
that provides the highest quality of life for End Stage Renal Disease patients
and ensures the return of the patient to full rehabilitation, the PhilHealth and
the Philippine Charity Sweepstakes Office (PCSO) shall provide support for all
maintenance immunosuppression for the lifetime of the transplant patient, as


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long as the transplanted organ is functioning and the patient remains
dialysis-independent.

All renal replacement therapy facilities shall be required to engaged in
regular organ donation advocacy activities that will provide education for all
Filipinos to carry the organ donor card. Facilities will likewise establish a
potential deceased organ donor referral system that will identify all potential
deceased organ donors to the Philippine Network for Organ Sharing.

SEC. 9. PhilHealth Benefit for Dialysis Treatment. - The PhilHealth shall
increase the Z-benefit package rate for the principal member and each of one’s
qualified dependent on maintenance dialysis per year for peritoneal dialysis
covering three (3) peritoneal dialysis exchanges per day for three hundred
sixty-five (365) days, while the package rate for hemodialysis treatment shall
be increased annually to cover a span of ninety (90) hemodialysis sessions per
year. The professional fee of the attending physician and hospital charges
shall be included in the PhilHealth benefits for dialysis treatment. The
remaining sessions for both peritoneal dialysis and hemodialysis shall be paid
for by the Philippine Charity Sweepstakes Office.

For purposes of providing optimal financial risk protection to the most
vulnerable groups including the poorest of the poor, the “No Balance Billing
Policy” of the government is hereby provided for indigents.

The breakdown of the PHIC hemodialysis benefit package shall include
standard HD treatment inclusive of the dialyzer and all other supplies needed
as well as the minimum basic laboratory tests consisting of complete blood
count, creatinine, calcium, phosphorus, potassium, albumin, hepatitis B
surface antigen (HBsAg) and anti-hepatitis C virus (Anti-HCV). The laboratory
tests shall be done at a frequency of at least four (4) tests per year for the first
six (6) tests, and twice a year for the last two (2) tests. The schedule of these
tests shall be determined by the attending physician during the course of the
annual dialysis treatment sessions.

SEC. 10. Periodic Assessment and Benefit Package Adjustments for End
Stage Renal Disease Patients. - A periodic assessment and reasonable
adjustments of the benefit package for dialysis and transplant patients shall
be made by the PhilHealth after taking into consideration its financial
sustainability and changes in the socio-economic conditions of the country.

SEC. 11. Free Dialysis Treatment to Indigent Patients. - Dialysis
treatment in all national, regional, and provincial hospitals shall be provided
free of charge to indigent patients as identified by the Department of Social
Welfare and Development using the National Household Targeting System for
Poverty Reduction. A PD First Policy shall be established for all indigent
patients, unless there is a contradiction to its use in a particular patient.

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SEC. 12. Treatment Options. ~The PhilHealth shall develop a package that
will provide the highest benefit for kidney transplant, followed by peritoneal
dialysis, then hemodialysis.

‘The benefit package shall include a screening test for both the donor
and recipient. The screening test for possible kidney transplantation of both
the donor and recipient shall include the following:

(1) For the donor, the screening testing include blood typing,
complete blood count, fasting blood sugar, creatinine, hepatitis B surface
antigen, anti-hepatitis C antibody, urinalysis, chest x-ray and ultrasound of
the kidneys, ureter and urinary bladder.

(2) For the recipient, cardiac evaluation and may other tests as
needed.

During the availment of the full benefits of dialysis within the first two
(2) years of dialysis initiation, the cost of dialysis treatment shall be paid for
by the PhilHealth and the PCSO as described in Section 8. These options are
provided to encourage more patients to have a kidney transplant and attain
full rehabilitation.

If the patient passes the criteria for the PhilHealth benefit package for
transplantation, the expenses for lab work-up shall be reimbursed to the
patient by the healthcare institution after the PhilHealth pays the benefit to
the healthcare institution.

‘The cost of the operation for transplantation shall be included in the
PhilHealth Z-benefit package which includes a month of post-hospital
discharge laboratory tests for the patient and a one (1) year follow up
laboratory tests for the donor. The Z-benefit package shall be expanded
accordingly.

‘The immunosuppression medications needed by the transplant patient,
if there is no graft rejection, shall be lifelong. For PhilHealth patients, these
medicines shall be provided for one (1) yea by PCSO. After the first year, the
patient may reapply with the PCSO for assistance for such medications.

SEC. 13. Rehabilitation Program. - The DOH, in coordination with the
Department of Labor and Employment, Technical Education and Skills
Development Authority, and the DSWD and other pertinent agencies, shall
establish a comprehensive rehabilitation program for ESRD patients who have
undergone kidney transplant in order to help them reach their fullest
physical, psychological, social, vocational, avocational, and educational
potential consistent with their physiologic or anatomic condition,
environmental limitations, life plans and desires.

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SEC. 14. Dialysis Facility. - A dialysis facility shall be compliant with the
licensing requirements imposed under DOH Administrative Order No. 2012-
0001 dated January 26, 2012 for hemodialysis, and PhilHealth-Accreditation
for peritoneal dialysis facilities. Hospitals without dialysis facilities first put
up the necessary equipment and qualified staff to perform peritoneal dialysis
services. For hospitals with existing hemodialysis facilities, a peritoneal
dialysis unit shall be established immediately so that this more cost-effective
dialysis option can be made available to patients. Hospitals shall
preferentially be provided with the necessary personnel, equipment and
supplies as required by PhilHealth for accredited facilities.

SEC. 15. Training for Peritoneal and Hemodialysis Treatment and
Services. - The DOH, National Kidney and Transplant Institute (NKTI) and
the Philippine Society of Nephrology (PSN) shall provide training for medical
personnel such as physicians to take charge of the hemodialysis and
peritoneal dialysis centers, hemodialysis and peritoneal dialysis nurse,
hemodialysis and peritoneal dialysis technicians, operating room nurses,
transplant ward nurses, transplant coordinators, and non-medical barangay
health workers to support home-based peritoneal dialysis. The NKTI shall
accredit the centers that can provide training for the above personnel and
training should include hands-on workshops for dialysis.

SEC. 16. Establishing a Chronic Kidney Disease (CKD) Counseling Clinic.
- All RRT facilities shall establish a chronic kidney disease (CKD) counseling
clinic with separate personnel trained to engage patients and explain to them
the normal functions of the kidney, the stages of CKD, the laboratories
routinely performed for CKD patients, the common medications required that
can control the progression of kidney disease, the metabolic complications of
ESRD, and the indications for renal replacement. These clinics shall monitor
the kidney function of patients so that a timely referral to a nephrologist or
internist/pediatrician with specialized training in CKD can be made, with the
timely initiation of Renal Replacement Therapy to prevent requiring
emergency treatment.

‘The NKTI shall provide education and training modules for the medical
staff of CKD counseling clinics.

SEC. 17. Creation of a Renal Disease Control Program (REDCOP). - All
RRT facilities shall create a Renal Disease Control Program (REDCOP),
following the model of the NKTI, that shall promote the early recognition of
kidney disease, identify persons at high risk for the development of kidney
disease and initiate preventive strategies to either prevent the development of
kidney disease (ie. From diabetes and hypertension) or to delay its progression
to end stage renal disease. The DOH will establish a database of these patients
to ensure that they are regularly monitored for disease progression and that
they are receiving the appropriate treatment for CKD.

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SEC. 18. Authority to Receive Donations and Exemptions from Donor’s
Taxes, Customs and Tariff Duties. -The DOH shall be authorized to receive
donations, gifts and bequests in order to augment the funding for the
establishment of the dialysis wards/units created in accordance with this Act.
All donations, contributions or endowments which may be made by persons
or entities to the dialysis wards/units in national, regional, and provincial
hospitals and the importation of medical equipment and machineries, spare
parts and other medical equipment used solely and exclusively by the dialysis
wards or units shall be exempt from income or donor’s taxes, ant other direct
or indirect taxes, wharfage fees and other charges and restrictions.

SEC. 19, Penalties. - Any hospital chief, administrator or office-in-charge of
hospitals, dialysis centers, and health facilities who fails to comply with
Sections 5 and 6 of this Act shall be meted with a fine of Fifty thousand pesos
(P50,0000.00) but not more than One hundred thousand pesos
(P100,000.00).

Likewise, persons receiving free treatment of medicines for End Stage
Renal Disease or PD or HD services from government hospitals and its
agencies (ie. PCSO, PHIC) who are found selling these medications or services
instead of using them for their own treatment, shall be penalized with the
suspension of their PhilHealth membership and shall be ineligible for
assistance from PCSO and other government agencies for a period of one (1)
year. If these persons are found to be engaged in the selling of medications or
services allotted for their care for the second time, they shall be permanently
ineligible to receive government assistance.

SEC. 20. Appropriations. - The initial amount necessary to implement the
provisions of this Act shall be charged against the current year’s appropriation
of the DOH. Thereafter, such sum as may be necessary for the continued
implementation of this Act shall be included in the annual General
Appropriations Act.

SEC. 21. Implementing Rules and Regulations. - Within sixty (60) days
from the effectivity of this Act, the Secretary of Health, in coordination with
the President of PhilHealth, the Executive Director of the NKTI, and other
relevant stakeholders, shall issue the implementing rules and regulations to
implement the provisions of this Act.

SEC. 22. Separability Clause. -If any provision or part hereof is held invalid
or unconstitutional, the remainder of the law or the provision not otherwise
affected shall remain valid and subsisting.

SEC. 23. Repealing Clause. - Any law, presidential decree or issuance,
executive order, letter of instruction, administrative order, rule or regulation


contrary to or inconsistent with the provisions of this Act are hereby repealed,
modified or amended accordingly.

SEC. 24. Effectivity. - This Act shall take effect fifteen (15) days after its
publication in the Official Gazette or a newspaper of general circulation.

Approved,