Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

18" Congress
First Regular Session

HOUSE BILL No, 2682

Introduced by: HON. LORNA C. SILVERIO

EXPLANATORY NOTE

The number of dialysis patients have been rising over the past decade and is
becoming a concern for us Filipinos. Kidney related diseases according to the
Department of Health (DOH) is the country’s 6" cause of death for the year 2013.
Patients’ profile have become younger and their number more than doubled from
4,000 cases last 2004 to more or less 23,000 in the 2013 figures released by the
DOH. The accessibility of dialysis treatment especially in the public sector has
been a challenge to people who are in dire need of this. For the treatment, the
patient must travel to urban cities for dialysis and it has become burdensome,
because we must remember that this is a regular treatment which is availed almost
thrice a week. The high cost and inaccessibility has been a concern for patients
especially the indigents who could not afford to travel and pay for a regular
dialysis cycle. In consonance with the government's efforts to make health services
accessible and affordable, the local governments must play an active role in being
the first line of providers for these people. A dialysis ward must be maintained and
operated by national, regional, and provincial government hospitals and prioritize
indigents living in the rural areas thus making the treatment free of any charge. Let
us make an efficient system wherein our constituents can freely avail of the basic
healthcare services the State is tasked to provide and promote.

In view of the foregoing, approval of this bill is earnestly sought.

LORNA C. SILVERIO


Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

18 Congress
First Regular Session

HOUSE BILL NO. _ 2682

Introduced by: HON. LORNA C. SILVERIO

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.”

Section 2. Declaration of Policy. It is a declared policy of the state to adopt an integrated and
comprehensive approach to health development that will 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 endeavour 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
underprivileged sick, elderly, disabled, women and children. The state shall endeavour 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.

Section 3. Definition of Terms.- As used in this Act:
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, hemodialysis;


b. End Stage Renal Disease or 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 or 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”,

d. 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 or 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’ life;

f 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;

8. No Balance Billing refers to the government policy of not charging the medical expenses
incurred and beyond the Philhealth package rates to a Philhealth member who has
undergone medical treatment;

h. Peritoneal dialysis or 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 exchange 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;

j. Renal replacement therapy or 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.

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


All national, provincial and regional 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
undergoiong 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.

Section 5. Chronic Kidney Disease (CKD) Prevention and Health Promotion — All national,
provincial, and regional government hospitals, and stand-alone dialysis facilities should establish
CKD prevention strategies and health promotion activities which includes: 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 form the government health centers such as those for diabetes and hypertension, and
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 activites pertaining
to the aforementioned programs should be documented accordingly.

Section 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

Section 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 hemodialyis 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.


Section 8, Philhealth Benefit for Kidney Transplantation — The PhilHealth benefit for kidney
transplantation from living doctors shall be expanded accordingly. This shall include the cost of
laboratory work up for both recepient and donor candidate, hospitalization for the transplant
operation induction imuunosuppression and maintenance oral imuunosuppression, 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 recepien, and up to I
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 recepient 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 the maintenance immunosuppression for the lifetime of the transplant
patient, as long as the transplanted organ is functioning and the patient remains dialysis
independent.

All renal replacement therapy facilities shall be required to engage in regular organ
donation advocacy activities that will provide education for all Filipnos 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.

Section 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 days (365 days), while the package rate for
hemodialysis treatment shall be increased annually to cover a span of ninety (90) hemodislysis
sessions per year. The professional fee of the attending physician and hospital charges shall be
included in the Philhealth benefits for dialysis treatment.

The remeining 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
laboratory tests consisting of complete blood count, creatinine, calcium, phosphorus, potassium,


albumin, hepatitis B surface antigen (HbsAg) and anti-hepatitis C (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.

Section 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 Philhealth after taking into consideration its financial
sustainability and changes in the socio-economic conditions of the country.

Section 11. Free Dialysis Treatment to Indigent Patients — Dialysis treatment in all national,
regional, and provincial government 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 estblished for all
indigent patients, unless there is a contraindication to its use in a particular patient.

Section 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 shall include a screening test for both the donor and recepient. The screening
test for possible kidney transplantation of both the donor and recepient 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 recepient, cardiac evaluation and many other tests as needed.

During the availment of the full benefits within the two (2) years of dialysis initiation,the
cost of dialysis treatment shall be paid for by the PhilHealth and the PCSO as desribed 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 health care 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 recepient 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 (1)


year by PCSO. After the first year, the patient may reapply with the PCSO for assistance for such
medications.

Section 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.

Section 14. Dialysis Facility — a dialysis facility shall be compliant with the licensing
requiremnts impopsed under DOH Administrative Order No. 2012-0001 dated January 26, 2012
for hemodialysis, and PhilHealth-Accreditation for peritoneal dialysis facilities. Hospital without
dialysis facilities first put up the necessary equipment and qualifed staff to perfoem 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.

Section 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 nurses,
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.

Section 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 emergency treatment.

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

Section 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 NKTTI, 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 (i 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 appropriate treatment
for CKD.

Section 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 requests 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 hopitals 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, any
other direct or indirect taxes, wharfage fees and other charges and restrictions.

Section 19. Penalty — Any hospital chief, administrator or officer-in-charge of hospitals, dialysis,
centers, and health facilities who fails to comply with Section 5 and 6 of this Act shall be meted
with a fine of Fifty thousand pesos (Php 50,000.00) but not more than One hundred thousand
pesos (Php 100,000.00).

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 permanently ineligible to receive government assistance.

Section 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
General Appropriations Act.

Section 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.

Section 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.