Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

NINETEENTH CONGRESS
First Regular Session

HOUSE BILL NO. 4248

Introduced by: Hon. Keith Micah “Atty. Mike” D.L. Tan

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

EXPLANATORY NOTE

Chronic Kidney Disease (CKD) is one of the primary causes of mortality
among Filipinos. According to the Department of Health, at least one Filipino dies
every hour from kidney failure

It 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.

Alarmingly, the number of Filipino suffering from kidney disease is on the rise.
In 2017 Philippine Renal Disease Registry, 21,535 Filipino was reported to have
started dialysis treatment as compare with 18,603 patients recorded in 2015. This
does not include patients who failed to get dialysis treatment due to high costs and
unavailability of health facilities.

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

Kidney disease cause 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 dialysis sessions 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.

It will not only provide accessible curative health services for CKD patients but
will also halt the rise in kidney-related diseases incidence through effective health
promotion.

‘Among its key provisions are 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 establishment of
dialysis services wards or units in all national, regional, and provincial government
hospitals.

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

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

D.L. Tan
4th District, Quezon


Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

NINETEENTH CONGRESS
First Regular Session

HOUSE BILLNo. 4248

Introduced by: Hon. Keith Micah “Atty. Mike” D.L. Tan

AN ACT
MANDATING THE PROVISION OF COMPREHENSIVE RENAL REPLACEMENT
THERAPY (RRT) TO PATIENTS WITH END STAGE RENAL DISEASE IN
NATIONAL, REGIONAL, AND PROVINCIAL GOVERNMENT HOSPITALS,
INCREASING FOR THE PURPOSE THE PHILHEALTH PACKAGE RATE FOR
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 the declared policy of the State to make
available essential goods, health and other social services to all citizens at affordable
cost and to deliver medical care to indigents free of charge. Pursuant to this, the
State shall continually improve the delivery of health services and hospital facilities to
make those accessible to all

In line with this policy, the State shall adopt an integrated and comprehensive
approach to health service delivery that shall include comprehensive renal
replacement therapy for patients who are diagnosed with End Stage Renal Disease
(ESRD).

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 support the
needs of a patient's 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 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 and assessed by the
social worker of the Department of Social Welfare and Development (DSWD) or the
social worker of the concerned local government unit;

e. Kidney Transplant or KT refers to a surgical procedure to place a
healthy kidney from a living 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 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 or the lining of the 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 a 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, regional, and provincial government hospitals, including all
stand-alone dialysis facilities shall establish, operate and maintain a dialysis service
facility in their hospitals. These dialysis facilities shall have all the necessary dialysis
machines, equipment and supplies. The same hospitals and dialysis facilities are
mandated to train nephrologists, dialysis nurses, dialysis technicians, and operating
room nurses in both peritoneal dialysis and hemodialysis.

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

The dialysis facilities shall further have a non-treatment place, which shall
serve as a waiting area for chronic kidney disease (CKD) patients and a business
area dedicated to the provision, display, and dissemination of information on the
prevention of CKD.


All patients diagnosed with ESRD shall be referred to a DOH-accredited
transplant facility to receive orientation and counseling on the advantages of
undergoing transplantation as the best treatment for kidney failure. They shall
likewise undergo medical evaluation for suitability of transplantation. All potential
organ donors of the patient shall be evaluated to determine compatibility. If no living
donors are available, the patient shall be enrolled in the deceased organ donor
waiting list to ensure that all patients with ESRD have the option to avail of kidney
transplantation

SEC. 5. Chronic Kidney Disease (CKD) Prevention and Health Promotion. -
A\ll national, regional, and provincial government hospitals, and stand-alone dialysis
facilities shall establish CKD prevention strategies and health promotion activities
which shall include advocacy activities targeting relatives of dialysis patients who are
at high risk in developing CKD themselves, the provision of instructional materials on
the common symptoms of kidney disease and regular conduct of educational
activities such as healthy diet and lifestyle, availment of regular tests to diagnose
kidney disease, information on 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 shall be informed on 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 check-up by a qualified
physician. All activities pertaining to the aforementioned programs shall be
documented accordingly.

SEC. 6. Quality Standards of Dialysis Services and Transplant Facilities. —
Hospitals and 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 shall
be required prior to the availment of both peritoneal dialysis and hemodialysis.

SEC. 8. PhilHealth Benefit for Kidney Transplantation - The PhilHealth Z-
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
hospitalization, and post discharge laboratory examinations up to one (1) month for
the recipient, and up to one (1) year for the donor.


The cost of organ retrieval and machine perfusion shall be established by the
DOH-Philippine Organ Donation and Transplant Program for all organ procurement
organizations or organ and tissue retrieval units.

The PhilHealth benefit package for kidney transplantation shall cover the
evaluation and screening of the kidney donor and recipient up to the transplant and
post-transplantation procedures and remedies and shall include cases involving
ESRD patients.

In order to support kidney transplantation as the best treatment option that
provides the highest quality of life for ESRD patients and ensures the return of the
patient to full rehabilitation, the PhilHealth shall provide lifetime support for all
maintenance immunosuppression 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. All donor- Filipino citizens shall carry the organ
donor card to be prescribed by the DOH. Health RRT facilities will likewise establish
an organ and tissue donor referral system that will identify all potential organ and
tissue donors to the Philippine Network for Organ Sharing (PhilNOS).

SEC. 9. PhilHealth Benefit for Dialysis Treatment. - The PhilHealth shall
increase the Z-benefit package rate for the principal member and the members’
qualified dependents for maintenance 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
minimum of three (3) hemodialysis sessions frequency a week, four (4) hours per
session, or as may be necessary. The professional fee of the attending physician
and hospital charges shall be included in the PhilHealth benefits for dialysis
treatment.

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, dialyzer and epoetin injection, 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. A PD First Policy shall be observed for all indigent
patients, unless there is a contraindication for its use in a particular patient.

SEC. 12. Treatment Options. - The PhilHealth shall develop a case rate
package that shall provide the highest benefit for a kidney transplant procedure,
peritoneal dialysis, and hemodialysis procedures.

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

1) Forthe donor, screening test shall 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 other tests as may be 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
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 Z-benefit package for
transplantation, the expenses for selected laboratory tests may be reimbursed to the
patient by the healthcare institution after the PhilHealth pays the benefit to the
healthcare institution.

SEC. 13. Rehabilitation Program. - The DOH, in coordination with the
Department of Labor and Employment, the Technical Education and Skills
Development Authority, the DSWD, and other pertinent agencies, shall establish a
comprehensive rehabilitation program for both kidney donors and dialysis patients
who have undergone kidney transplant procedure in order to help them reach their
fullest physical, psychological, social, vocational, 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 by DOH for hemodialysis. Hospitals without dialysis
facilities shall provide the necessary equipment and qualified staff to perform
peritoneal dialysis services. Hospitals with existing hemodialysis facilities only, shall
immediately establish a peritoneal dialysis unit to provide cost-effective dialysis
option to patients. Hospitals shall equip itself with the necessary personnel,
equipment and supplies as required by PhilHealth.

SEC. 15. Training for Peritoneal and Hemodialysis, and Transplant Treatment
and Services. - The DOH, National Kidney and Transplant Institute (NKTI), Philippine
Society for Transplant Surgeons (PSTS), and the Philippine Society of Nephrology


(PSN) shall provide training for medical personnel such as physicians, surgeons,
nurses, technicians and coordinators who shall take charge of the hemodialysis and
peritoneal dialysis centers, operating rooms, transplant wards, and for non-medical
barangay health workers who shall assist home based peritoneal dialysis. The NKTI
shall accredit the centers that can provide training for these personnel and the
training shall include hands-on workshops for dialysis.

SEC. 16. Establishing a Chronic Kidney Disease (CKD) Counseling Clinic. -
All RRT facilities shall establish a CKD counseling clinic and shall separately provide
personnel trained to engage patients and explain to them the normal functions of the
kidney, the stages of CKD, the laboratory examinations 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 internis/pediatrician with specialized training in
CKD can be made.

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

SEC. 17. Availment of Persons with Disability (PWD) Benefits by CKD
Patients. CKD patients shall be classified as PWD, who shall be entitled to PWD
benefits, in accordance with Republic Act No. 7277, otherwise known as the Magna
Carta for Disabled Persons. The PhilHealth and DOH Health Technology
Assessment Council shall conduct an in-depth study on both the direct and indirect
cost of being affected with kidney disease and to undergo treatment for it.

SEC. 18. Creation of a Renal Disease Control Program (REDCOP). - All RRT
facilities shall create a Renal Disease Control Program (REDCOP) that shall
promote the early recognition of kidney disease, identify persons at high risk of
developing kidney disease and initiate preventive strategies to either prevent the
development of kidney disease 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. 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 ESRD, PD or HD
services from government hospitals, such as the 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 other government
agencies for a period of six (6) months, upon due process and hearing. 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 appropriations 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 ninety (90) days from
the effectivity of this Act, the DOH shall, in coordination with the PhilHealth, the
NKTI, and other relevant stakeholders, 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,