Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH CONGRESS
First Regular Session

251
HOUSE BILL No.

Introduced by
BAYAN MUNA Party-List Representatives FERDINAND R. GAITE,
CARLOS ISAGANI T. ZARATE, and EUFEMIA C. CULLAMAT,
ACT TEACHERS Party-List Representative FRANCE L. CASTRO, GABRIELA.
‘Women’s Party Representative ARLENE D. BROSAS,
and KABATAAN Party-List Representative SARAH JANE I, ELAGO

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

EXPLANATORY NOTE

Renal disease is one of the top ten (10) causes of death among Filipinos, according to the
Department of Health. Seven thousand patients die annually due to kidney malfunction in the
country. There are at least 120,000 cases of kidney failure each year, according to Antonio
Paraiso, DOH program manager for the Philippine Network for Organ Sharing. Some sixty
percent (60%) of patients with chronic kidney failure are service patients, said a study conducted
by the Philippine Society of Nephrology’.

Every year, the number of patients undergoing dialysis is increasing. From 4,000 dialysis
patients in 2004 recorded by DOH, the number rose to 23,000 by 2013. For two-to-three times
dialysis sessions a week, a patient has to spend P25,000 to P46,000 a month or P300,000 to
P552,000 a year. On top of this, maintenance medication also costs about P20,000 a month?
With an average monthly income of only P4,838.16, most of patients with chronic renal disease
could not afford treatment, according to a research conducted by Dr. Romina Danguilan.

In 2015, some 691,489 claims were filed for hemodialysis, the most among procedures covered
by PhilHealth. The total benefits paid were P4.67 billion. Yet, patients with PhilHealth coverage
can only claim half of the cost of their treatment. According to the National Kidney and

2 http://www.chdphilippines.org/2015/06/the-worsening-problem-of-renal-diseases/


Transplant Institute (NKTI), only 15% of the partially-subsidized patients are PhilHealth
members*.

Because of the high cost of hemodialysis, poor patients had to beg around for funds to pay for
their treatment. Many of them regularly solicit funds at the offices of the members of Congress at
the House of Representatives, Philippine Charity Sweepstakes Office, and offices of political
parties and charitable organizations. Poor kidney patients survive, either in deep debt or in
begging around.

Dialysis services are inadequate especially in regions and far flung areas. Even NKTI, the
government's specialty health facility for kidney transplant and kidney-related diseases, was only
able to serve 27% or 723 service patients while 1,971 or 73% were pay patients out of the total
2,694 out patients served in January 2015. NKTI said that with limited income and resources, it
can hardly afford to expand its services. While there are regional or provincial hospitals with a
dialysis facility, most are presumably just like in NKTI, where there is no “free treatment” for
renal diseases

In 2015, during the 16% Congress, the House of Representatives approved House Bill 5956
mandating the Philippine Health Insurance Corporation to increase the coverage for dialysis
treatment to ninety (90) sessions per year. PhilHealth accordingly issued Circular No. 024-2015
dated August 27, 2015 that increased the dialysis sessions covered by Philhealth from 45 to 90
sessions per year and pegged hemodialysis cost to P2,600 per session from the previous P4,000
per session. The new hemodialysis package includes facilities and dialysis machine use, drugs
and medicine (0.9 sodium chloride, heparin, bicarbonate or acetate hemodialysis solution, e cart
drugs), supplies and others (fistula kits, blood tubing, dialyzer (low flux), syringe, and gauze) and
professional fee. However, the new package no longer includes the injection of epoetin alpha or
beta previously included in the old Philhealth’s case rate for hemodialysis.

jents complained of increased out-of-pocket expenses in the form of co-pay mechanisms and
injections and laboratory procedures which they now have to shoulder. According to
Hemodialysis Patient Organization, the co-pay charge per session was increased by P350- P5S0
per hemodialysis session. Injection of epoetin drug costs P1,200-2,400 per session, bringing the
cash-out of patients to P1,500 to P3,000 per hemodialysis session. In 2016, the monthly cash-out
of patients can run as high as P 13,752-P19,054. The amount does not even include the laboratory
procedure expenses. According to NKTI*, the hospital has to charge co-pay otherwise it would
incur losses as a result of the reduction of PhilHealth benefits;

In response to the clamor of dialysis patients, Bayan Muna Party-List representatives filed House
Resolution No. 1761 to investigate the plight of peritoneal dialysis patients during the 16
Congress, and a similar House Resolution No. 244 during the 17" Congress. HR 244 became one
of the measures consolidated into House Bill 9156 or Comprehensive Renal Replacement
Therapy bill whih in turn was passed on Third Reading.

Accessibility and affordability of dialysis treatment and renal transplantation may spell the
difference between life and death for many end stage renal disease patients especially the
indigents. This bill thus provides comprehensive, accessible and free dialysis and transplantation,
and preventive measures and treatment for chronic kidney diseases with the hope of saving as
many lives as possible.

Immediate passage of this bill, thus, is earnestly sought.

2 Ibid.
“Letter addressed to Bayan Muna Rep. Neri Colmenares signed by NKTI Executive Director Jose Dante P. Dator
dated January 27, 2016

2


Approved,
REP. FERDINAND R. GAITE REP. eu fii CULLAMAT
BAYAN MUNA Partylist BAYAN MUNA Partylist

;
nor Sea
BAYAN Mt 1A Partylist

4 D. BROSAS REP. JANE I. ELAGO
“ABRIELK Women’s Party (TAAN Pasty-List


Republic of the Philippines
HOUSE OF REPRESENTATIVES,
Quezon City

EIGHTEENTH CONGRESS
First Regular Session

HOUSE BILL No.__291

Introduced by
BAYAN MUNA Party-List Representatives FERDINAND R. GAITE,
CARLOS ISAGANI T. ZARATE, and EUFEMIA C. CULLAMAT,
ACT TEACHERS Party-List Representative FRANCE L. CASTRO, GABRIELA
Women’s Party Representative ARLENE D. BROSAS,
and KABATAAN Party-List Representative SARAH JANE I. ELAGO

AN ACT PROVIDING A COMPREHENSIVE RENAL REPLACEMENT THERAPY
(RRT) FOR PATIENTS WITH END STAGE RENAL DISEASE IN NATIONAL,
REGIONAL, AND PROVINCIAL GOVERNMENT HOSPITALS AND 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, and specifically, 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. Dialysis will be provided in the form of peritoneal dialysis as the first option to
attain adequate dialysis, followed by hemodialysis. Transplant facilities will be provided in
strategic areas in the country and hospital facilities equipped to provide peritoneal dialysis
and hemodialysis will be made available, affordable and accessible to the people.

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 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. An indigent is 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 subdivision, 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
the blood;

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 all 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 medicines 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
ies 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 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 PHIC benefits for both peritoneal dialysis and
hemodialysis.

6


SEC. 8, PhilHealth Benefit for Kidney Transplantation - The PhilHealth benefit for a Kidney
Transplantation from living donors shall be expanded accordingly. This includes the cost of
laboratory work-up for both recipient and donor candidate, hospitalization for the transplant
operation including induction immunosuppression and maintenance oral immunosuppression,
to machine perfusion of procured organs and 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 Imonth 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, 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. - 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 365 days, while the package rate for hemodialysis treatment shall be increased
annually covering a span of one hundred fifty-six (156) 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 provided 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-
HCY). The laboratory tests shall be done at a frequency of at least four (4) tests per year for
the first 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 benefit 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 would
include, but not limited to, 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

ient, 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 provided for by 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 passed 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 PhilHealth pays the benefit to the healthcare institution.

The cost of the operation for transplantation is also included in the PHIC 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 are provided for
one (1) year by PCSO. After that 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 one’s physiologic or anatomic condition, environmental limitations, life plans and
desires.

SEC. 14. Dialysis Facility. ‘The dialysis facility shall be compliant with the Licensing
Requirements imposed by the DOH under DOH Administrative Order No. 2012-0001 dated
January 26, 2012 for hemodialysis, and PhilHealth-Accreditation for peritoneal dialysis

qualified staff to perform peritoneal dialysis. For hospitals with existing hemodialysis
facilities, a peritoneal dialysis unit should 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 (nephrologists, physician-on-duty for
hemodialysis 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 fun 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 (i.e. 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 (i.e. PCSO, PhilHealth)
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 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 in a newspaper of general circulation.

Approved,

10