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Introduced by HON. RUTH MARIANO-HERNANDEZ

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

In the 16", 17 and 18" Congresses, various lawmakers pushed for measures to
increase the health coverage for the treatment of kidney disease of Filipinos.

Reps. Francis Calalay and Leopoldo Bataoil introduced House Bill 5956 to increase the
coverage for dialysis treatment for Filipinos. It was passed on third reading by the
House of Representatives in the 16" Congress.

In the 17th Congress, House Bill 9156, or the Comprehensive Renal Replacement
‘Therapy Act, was authored by Rep. Joseph Stephen Paduano to further improve the
quality of renal health services in the country. It also passed on third reading in the
House of Representatives.

In the 18th Congress, House Bill 6803 primarily authored by Reps. Angelina Tan, M.D.
and Jose Christopher Belmonte was passed on third reading by the House of
Representatives and was transmitted to the Senate for appropriate action. But the
Senate failed to act on the said measure.

This bill needs to be enacted to fulfill the mandate to make health services affordable to
all Filipinos, as stated in Article XIII, Section 11 of the 1987 Philippine Constitution:

|
“The State shall adopt an integrated and comprehensive approach to health
development which shall endeavor to make essential goods, health and other social



services available to all the people at affordable cost. There shall be priority for the
needs of the underprivileged, sick, elderly, disabled, women, and children. The State
shall endeavor to provide free medical care to paupers.”

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

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

The optimum frequency of dialysis treatment is three times a week. But some Filipino
patients settle for once- or twice-a-week sessions due to the prohibitively high costs and
inaccessibility. Some patients even die without the chance to undergo the treatment
because they cannot afford it.

But it is important to recognize that dialysis treatments merely serve as a temporary
lifeline for kidney patients to survive. Nephrologists note that kidney transplants
remain to be the best form of renal replacement therapy

This bill aims to provide cost-effective renal replacement therapy for Filipinos.

The measure hereby seeks to establish facilities that would provide quality renal health
by mandating health facilities in the national, regional and provincial levels that will
give free dialysis for indigent Filipinos.

It likewise aims to develop PhilHeath packages that would cover expenses for renal
patients to undergo kidney transplant procedures and extend these packages to the
living kidney donors for the cost of laboratory work-up, hospitalization and
medications.

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



Republic of the Philippines
HOUSE OF REPRESENTATIVES
Quezon City

NINETEENTH CONGRESS
First Regular Session

| HOUSE BILL NO. 1722

Introduced by HON. RUTH MARIANO-HERNANDEZ

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
accessibl¢ 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 ofa patient's daily life;


>

lemodialysis or HD refers to a medical procedure to remove fluid and waste
oducts from the blood and to correct electrolyte imbalances using a
synthetic membrane or dialyzer which is also referred to as an “artificial
idney”;

Indigent refers to a patient who has no source of income or whose income is
not sufficient for family subsistence as identified and assesed by the social
worker of the Department of Social Welfare and Development (DSWD) or the
social worker of the concerned local government unit;

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;

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;

‘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 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;

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
hospitals

cilities shall establish, operate and maintain a dialysis service facility in their
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 hee and counseling on the advantages of undergoing transplantation as
the best treatment for kidney failure. They shall likewise undergo medical evaluation for
suitability bf 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.

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.

SECS. an ‘Kidney Disease (CKD) Prevention and Health Promotion, - All national,

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.

Patients vn their relatives shall be informed on the availability of the proper medicines

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. 6. See Standards of Dialysis Services and Transplant Facilities. - Hospitals

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.7. rh Renal Disease Registry.- Private and public hospitals, dialysis centers

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 ren retrieval, all medications required during hospitalization, and post
discharge laboratory examinations up to one (1) month for the recipient, and up to one
(4) 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.

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).

All renal ress therapy facilities shall be required to engage in regular organ

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 shalll 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 bpyided 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 fo alalyss 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 benef{t 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) For the 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, persting 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. iblishing 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 dian 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.

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)..



governme!

it hospitals, such as the PHIC, who are found selling these medications or

Likewise, hs receiving free treatment of medicines for ESRD, PD or HD services from

services i
suspension
of six (6) mi
in the selli
shall be pel

tead of using them for their own treatment, shall be penalized with the
of their PhilHealth membership and other government agencies for a period
nths, upon due process and hearing. If these persons are found to be engaged
ig of medications or services allotted for their care for the second time, they
‘manently 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
included i

1s may be necessary for the continued implementation of this Act shall be
the annual General Appropriations Act.

SEC. 21. Implementing Rules and Regulations. - Within ninety (90) days from the

effectivity pf this Act, the DOH shall, in coordination with the PhilHealth, the NKTI, and
other relent 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. Repeating Clause. - Any law, presidential decree or issuance, executive order,

letter of i
with the p

SEC. 24. Ef
Official Gai

Approved,

struction, administrative order, rule or regulation contrary to or inconsistent

‘ovisions of this Act are hereby repealed, modified or amended accordingly.

tivity. - This Act shall take effect fifteen (15) days after its publication in the
vette or in a newspaper of general circulation.