Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH CONGRESS
First Regular Session
436

HOUSE BILL NO.

Introduced by HONORABLE STRIKE B. REVILLA

EXPLANATORY NOTE

Kidney problems consistently rank in the top 10 causes of death both in the
Philippines and worldwide. For the indigent Filipino, the cost of dialysis at Php 2,500.00 per
session is a heavy burden.

Given the current situation of kidney disease, a State provision for this particular
health care issue is necessary. The increase in the cases entails an increase in support by the
State, especially for indigent patients.

With this bill, the need is addressed by establishing dialysis clinics in all national,
regional, and provincial hospitals in the country. The National Kidney and Transplant
Institute serves an average of 34,000 dialysis sessions every year, including patients from
outside of Metro Manila. Branching out dialysis treatment for free to the regions and
provinces would help in battling chronic kidney disease in the country.

REP. AS, REVILLA
2

District, Cavite


Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

EIGHTEENTH CONGRESS
First Regular Session

436
HOUSE BILL NO.

Introduced by HONORABLE STRIKE B. REVILLA

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.

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.
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SEC. 3. Definition of Terms. — As used in this Act:

. 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 the daily life;

. Hemodialysis or HD refers to a medical procedure to remove fluid and waste products from
the blood and correct electrolyte imbalances. This is accomplished using a synthetic
membrane or dialyzer which is also referred to as “artificial kidney”;

|. 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;

. 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 standalone 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 the abdominal cavity) as the membrane through

which fluid and toxic substances are exchanged with blood;

PD First Policy refers to the policy where peritoneal dialysis, when feasible, is offered as the

first dialysis modality to RRT patients;

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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, and
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 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 counselled 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, regional, and provincial 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 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

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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 cli
activities pertaining to the aforementioned programs should be documented accordingly.

ic follow-up with a qualified physician. All

SEC. 6. - Quality Standard 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.

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 ong 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 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 days (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
id hereby provided for indigents.

The breakdown of the PHC 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

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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 treatments 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. - Treament Options. ~ The PhilHealth shall develop a package that will provide
the highest benefit for kidney transplant, followed by peritoneal dialysis, the 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 the transplantation shall be included in the PhilHealth Z-
benefit package which includes a month of post-hospital discharge laboratory tests for the

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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 PSO. 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 the DOH Administrative Order No. 2012-0001 dated January
26, 2012 for hemodialysis, and PhilHealth-Accreditation for peritoneal dialysis faci
Hospitals without dialysis faci
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 preferably be provided with
the necessary personnel, equipment and supplies as required by PhilHealth for accredited

ies.

‘ies first put up the necessary equipment and qualified staff to

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 centers that can provide training for the
above personnel and training should include hands-on workshops for dialysis.

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SEC. 16. Establishing a Chronic Kidney Disease (CKD) Counselling Clinic. — All RRT
facilities shall establish a chronic kidney disease (CKD) counselling 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 or CKD

counselling 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 (je. 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, 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 government
hospitals and the importation of medical equipment and machineries, spare parts and other
medical equipment used solely and exclusively by the dialysis wards/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 of officer-in-charge of hospitals,
dialysis centers, and health facilities who fails to comply with Sections 5 and 6 of this Act
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shall be meted with a fine of Fifty Thousand Pesos (P50,000.00) but not more than One
Hundred Thousand Pesos (100,000.00).

Likewise, persons receiving free treatment of medicines for End Stage Renal Disease

or PD or HD services from government hospitals and its agencies (ie. PCSO, PHIC) who are
found selling these medicines 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 the
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 provisions 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 is 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 two (2) newspapers of general circulation.

Approved,
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