Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH CONGRESS
First Regular Session

HOUSE BILL NO. 189

Introduced by: Hon. Angelina “Helen” D.L. Tan, M.D.

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.

EXPLANATORY NOTE

It is estimated that around 28,000 patients are undergoing dialysis treatment in the Philippines
as of 2016. Kidney disease has been identified as one of the top 10 causes of death in the country
where the number of dialysis patients have been steadily increasing at 10% to 15% annually.

In 2014, the Philippine Health Insurance Corporation (PhilHealth) paid a total of Php4.7 Billion
arising from 691,489 claims for dialysis treatment.

While kidney disease might not have been the primary cause of death in the country, it causes
the kidney patients their minuscule income to sustain the treatment needed to manage the disease.
The 45 sessions of dialysis subsidy given by Philhealth annually is not enough to endure the never-
ending dialysis session for kidney patients. On average, a kidney patient spends Php12,000.00 per
month for his dialysis session once a week. In addition, patients from rural areas spend for travel
‘expenses to avail the complete dialysis in hospitals located in highly urbanized cities.

This measure aims to make comprehensive renal replacement therapy services available to all

Filipinos who suffer from End Stage Kidney Disease by including it in the coverage of treatment
services provided by the PhilHealth. It also supports 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.

‘Among its key provisions, to name a few, includes the expansion of PhilHealth benefit package

for kidney transplantation or renal replacement therapy from both the living and deceased donors;
provision of free dialysis to indigent patients; and provision by the Philippine Charity Sweepstakes
Office of the remaining needed sessions for both peritoneal dialysis and hemodialysis after a patient
has already consumed his or her benefit package from PhilHealth.

The rationale of this measure is in consonance with the Constitutional mandate to make health
services available to our countrymen at affordable cost.

Hence, immediate approval of this proposed measure is earnestly sought

ANGELINA “HELEN” u TAN, M.D.
4th District, Quezon


Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH CONGRESS
First Regular Session

HOUSE BILL NO. 169

Introduced by: Hon. Angelina “Helen” D.L. Tan, M.D.

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 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 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.

It is also hereby deciared 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;

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;

c 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’s 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,

g. 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 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;

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, 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. Philtlealth 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 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. PhilH/ealth 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 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 Phillealth Z-benefit
package which includes a month of post-hospital discharge laboratory tests for the recipient and a one
(A) 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.

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 Ciinic. - 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
dlinics,

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

Approved,