Health and finance professionals propose the use of artificial intelligence (AI) among private hospitals and the state-run Philippine Health Insurance Corporation (PhilHealth) as a way to ensure hospitals’ profits.

Philippine Hospital Association vice president for Private Hospital Affairs Dr. Jaime Almora raised the need for AI as data from the Philippine Institute for Development Studies (PIDS) affirms PhilHealth’s inaccurate payments of claims to hospitals.

“Our analysis of hospital financial statements reveals a downward trend,” PIDS senior research fellow Dr. Valerie Gilbert Ulep said in the recent launch of the government’s Health Economics and Finance Program.

The program aims to create data-based rates for PhilHealth benefits and hospital payouts that reflect the latest prices of medical procedures and medicines health providers give to patients for their optimal recovery results.

PhilHealth’s revenue share

According to PIDS, the share of PhilHealth in revenues of private hospitals declined from over 50 percent in 2015 to below 40 percent in the past four years.

Almora said AI-based data sharing can reflect specific prices and details on the medicines given to patients and the medical procedures they underwent. He added that digital technology can also speed up submissions of patients’ bills to PhilHealth for hospital claims.

“The pay-for-service method is the best source for computing patients’ benefits from PhilHealth. But I understand that this is laborious and unpredictable for PhilHealth and can delay its payouts to hospitals,” he said.

“With AI, there can be real-time submissions of claims based on patients’ clinical records,” Almora continued.

Philippine Medical Association assistant secretary general Dr. Ma. Realiza Henson said PhilHealth must employ medical specialists to help it refine benefits rates for patients.

“This is important so that the PhilHealth formulas will be updated,” she said.

Aim for best possible treatment

Philippine College of Surgeons Chairperson Dr. Manuel Francisco Roxas added PhilHealth must aim for the possible best treatment patients can avail using the state-owned insurers’ benefit packages.

“PhilHealth needs to allow hospitals more flexibility on how they are going to treat the disease. For example, colorectal cancer requires chemotherapy and several other procedures. Quality means better outcomes,” he said.

Ulep warned that many Filipinos could receive poorer healthcare due to hospitals’ declining profits as they struggle to acquire modern equipment, attract highly skilled medical workers, and build convenient facilities.

PIDS data reveal Filipinos shouldered 44.4 percent of their total medical expenses in 2023 despite the implementation of the Universal Health Care Act.

Moreover, more than 1 million households suffered catastrophic medical situations during that period, including cancer which is the second major cause of death among Filipinos.