Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH (18%) CONGRESS
First Regular Session

HOUSE BILL NO.. 163

Introduced by REP. JOSE CHRISTOPHER Y. BELMONTE

EXPLANATORY NOTE

In the 16% Congress, House Bill No. 5956, aiming to increase the coverage for dialysis
treatment for Filipinos, was introduced by Rep. Francis Calalay and Rep. Leopoldo Bataoil. It was
passed on 3" reading by the House of Representatives.

Subsequently, in the 17 Congress, House Bill No. 9156, or the Comprehensive Renal
Replacement Therapy Act, was principally authored by Rep. Joseph Stephen S. Paduano to further
improve the quality of renal health service in the Philippines. It passed on 3" reading and was
transmitted to the Senate of the Philippines for appropriate actions, but the Senate failed to act on
the proposed bill.

This bill is yet to be enacted to fulfill its mandate to make social services such health
affordable to all Filipinos, as stated in Section 11, Article XIII:

“The State shall adopt an integrated and comprehensive approach to health
development which 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 underprivileged, sick, elderly, disabled, women, and children. The
State shall endeavor to provide free medical care to paupers.

One of the primary causes of mortality among Filipinos is Chronic Kidney Disease (CKD).
Every hour, one Filipino or about 120 Filipinos per million population dies because of End Stage
Renal Disease (ESRD), the last stage of CKD. The numbers continue to rise as experts noted that
there is around 10-20 percent increase in the new patients undergoing dialysis in 2018.



In a data from the Philippine Renal Disease Registry, 18,603 new Filipino patients
underwent dialysis in 2015 and by the end of that year, it rose to 32,077. From this statistic, only
475 or 1.5 percent Filipino patients received kidney transplant.

The optimum frequency of dialysis treatment is three times a week. But some Filipino
patients would settle with once or twice a week because of its high cost and, sometimes,
inaccessibility. In turn, their health would deteriorate progressively. Worse, some patients would
even die without even the chance to undergo the treatment because they could not afford it.

However, dialysis treatments only serve as a ‘bridge’ for patients to survive. Nephrologist
have noted that kidney transplant remains to be the best form of renal replacement therapy. But
this procedure is costlier than dialysis treatment. Renal Gift Allowing Life for Others (REGALO),
an organ donor advocacy group, also cited a lack in the number of kidney donors in the country.

This bill seeks to establish facilities that would provide quality renal health service for
Filipinos. It will also establish health facilities in the national, regional and provincial levels that
will give free dialysis for indigent Filipinos. It likewise aims to increase the number of Filipinos
renal patients to undergo kidney transplant procedures by developing PhilHeath packages that
would cover for their expenses. These packages extend to the living kidney donors including the
cost of laboratory work-up, hospitalization, and all medications. This bill will provide available
and cost-effective renal replacement therapy for Filipinos.

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

Jeepelont


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Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH (18%) CONGRESS
First Regular Session

163
HOUSE BILL NO,

Introduced by REP. JOSE CHRISTOPHER Y. BELMONTE

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 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


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Itis 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

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;

. 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”;

Indigent refers to a patient who has no source of income or whose income isnot
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;

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’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;

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 exchanged with blood;


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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.

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, provincial, and regional 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, 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
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, provincial, and regional 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,


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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
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.


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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 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 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 As:
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

-ssment and Benefit Package Adjustments for End Stage Renal



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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 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
established for all indigent patients, unless there is a contraindication to its use in a particular
patient.

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


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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.

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
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.

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.


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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 appropriate
treatment for CKD.

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, any other direct or indirect taxes,
wharfage fees and other charges and restrictions,

SEC. 19. Penalty. - Any hospital chief, administrator or officer-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 (P50,000.00) 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. /mplementing Rules and Regulations — Within sixty (60) days from the
effectivity of this Act, the Secretary of Health, in coordination with the President of


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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 in a newspaper of general circulation.

Approved,