REPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH OFFICE OF THE SECRETARY ADMINISTRATIVE ORDER NO.

2008 - 0001 January 7, 2008

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SUBJECT: Implementing Rules and Regulations of Republic Act No. 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses". I. Rationale: The passage of Republic Act (R.A.) No. 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses", addresses the problem involving some hospitals and medical clinics that refuse to discharge patients due to the latter's inability to pay their hospital bills or medical expenses by encouraging them to employ appropriate payment schemes. It also emphasizes the responsibility of patients to honor their obligation with the hospital or medical clinic to pay their bills. Section 4 of R. A. No. 9439 authorizes the Department of Health (DOH) to promulgate the necessary rules and regulations. II. Objective: This Administrative Order sets the implementing rules and regulations to carry out the provisions of R. A. No. 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals -and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses". III. Scope: This Administrative Order applies to patients admitted in government and private hospitals and medical clinics, except those who stay in private rooms. IV. Definition of Terms: For purposes of R. A. No. 9439 and its implementing rules and regulations, the following definitions are provided: A. Co-Maker - a person, natural or juridical, who binds himself jointly and severally to pay the unpaid hospital bills or medical expenses/hospitalization expenses of the patient. B. Complaint - a sworn written statement of ultimate facts, filed by the patient, charging the official or employee of the hospital or medical clinic with any violation of R. A.. No. 9439 and its implementing rules and regulations. C. Detention - an act of restraining a person from leaving the hospital premises for nonpayment of hospital bills or medical expenses in part or in full. D. Guarantee - an expressed assurance by the co-maker to the hospital or medical clinic that certain facts or conditions are true and/or will happen. The hospital or medical clinic is permitted to rely on that assurance

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seek

appropriate

action

if

it

is

not

true

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followed.

E. Hospital - a health facility for the diagnosis, treatment and other forms of health care of individuals suffering from deformity, disease, illness or injury, or in need of surgical, obstetrical, medical or nursing care. It is an institution where there are installed bassinets or beds for 24-hour use or longer by patients in the management of deformities, diseases, injuries, abnormal physical and mental conditions, and maternity cases. F. Hospital Bills or Medical Expenses/ Hospitalization Expenses - costs of diagnosis, treatment and other forms of health care of patients, which include, but not limited to, doctor's fees, amount owing for clinical and ancillary services rendered, charges for room, meals, medical supplies, drugs and medicines, and payments for use of equipment. G. Medical Clinic - a health facility that satisfies the above definition of a hospital but uses the phrase "medical clinic" in its business name. H. Mortgage - a method of using real property (land) or personal property (other physical possessions) as security for the payment of a debt. I. Officer or Employee of a hospital or medical clinic - a person acting in behalf of a hospital or medical clinic responsible for releasing patients in accordance with written policies and procedures of the hospital or medical clinic. J. Patient - for the purposes of R. A. No. 9439 and these implementing rules and regulations, a person who is already admitted and availed of health care services in a hospital or medical clinic. K. Private Room - a single occupancy room or a ward type room divided by either a permanent or semipermanent partition (except curtains) not to exceed 4 patients per room who are admitted for diagnosis, treatment and other forms of health care maintenance. L. Promissory Note - an unconditional promise in writing made by the patient and/or his/ her next of kin to the hospital or medical clinic, engaging to pay on demand, or at a fixed or determinable future time, a sum certain in money to order or to bearer. V. Policies and Guidelines: A. General Policies: 1. Patients, except those who stay in private rooms, who are partially or fully recovered and who wish to leave the hospital or medical clinic but are incapable to pay, in part or in full, their hospital bills or medical expenses/ hospitalization expenses shall be allowed to leave the hospital or medical clinic and shall be issued the corresponding medical certificate and other pertinent documents for their release from the hospital or medical clinic upon execution of a promissory note covering the unpaid obligations. The promissory note shall be secured by either a mortgage, or a guarantee of a co-maker who shall be jointly and severally liable for the unpaid obligations. 2. In the case of a deceased patient, any of his/ her surviving relatives shall be issued the corresponding death certificate and other pertinent documents for interment purpose only. For other purposes, such documents shall be issued only upon execution of a promissory note covering the unpaid obligations by any of the surviving relatives. The promissory note shall be secured by either a mortgage, or a guarantee of a comaker who shall be jointly and severally liable for the unpaid obligations. In the event the documents will be needed for purposes of getting the benefits from the Social Security System. Government Service Insurance System, Philippine Health Insurance Corporation, insurance policies or pre-need plans, the hospital may require the execution of an assignment of proceeds up to the extent of the hospital bills or medical expenses/ hospitalization expenses. 3. In the case of a deceased patient, any of his/ her surviving relatives who refuse to execute a promissory note shall be allowed to claim the cadaver and can demand the issuance of death certificate and other pertinent documents for interment purposes. Documents for other purposes shall be released only after

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4. Any hospital or medical clinic detaining or causing, directly or indirectly, the detention of patient for reason of nonpayment, in part or in full, of hospital bills or medical expenses/ hospitalization expenses shall be held accountable for such unlawful act. Detention occurs when all of the following are present: a) The patient who is partially or fully recovered has expressed his/ her intention to leave the hospital or medical clinic, or the attending physician has issued a discharge order; b) The patient is not confined in a private room and is financially incapable to settle in part or in full the corresponding hospital bills or medical expenses/ hospitalization expenses; c) Patient has executed a promissory note covering the unpaid hospital bills or medical expenses/ hospitalization expenses; and d) The officer or employee of the hospital or medical clinic responsible for releasing the patient has restrained him from leaving the hospital premises. 5. In the case of a deceased patient, any hospital or medical clinic refusing to release the cadaver for reason of nonpayment, in part or in full, of hospital bills or medical expenses/ hospitalization expenses shall be held accountable for such unlawful act. Detention occurs when all of the following are present: a) The medical officer has made the pronouncement of death;

b) Any of the surviving relatives is incapable to pay the corresponding hospital bills or medical expenses/ hospitalization expenses; c) Any of the surviving relatives has executed a promissory note covering the unpaid hospital bills or medical expenses/hospitalization expenses; and d) The officer or employee of the hospital or medical clinic responsible for releasing the deceased patient has refused to release the cadaver and/ or relevant documents. B. Specific Guidelines: 1. Classification, Admission and Discharge of Patients

To minimize, if not prevent, incidence of patients being unable to pay, and hospitals or medical clinics detaining patients for reason of nonpayment of hospital bills or medical expenses/ hospitalization expenses, patients and hospitals or medical clinics alike may institute and observe the following: a) Government hospitals or medical clinics shall classify patients in terms of their capacity to pay according to the guidelines set by the DOH in Administrative Order No. 51-A s. 2000: Implementing Guidelines on Classification of Patients and on Availment of Medical Social Services in Government Hospitals, dated October 12, 2001. b) Private hospitals or medical clinics shall have written policies and procedures to classify patients in terms of their capacity to pay. For this purpose, private hospitals or medical clinics may refer to AO No. 51-A s. 2000. c) The DOH, government and private hospitals or medical clinics shall, as far as practicable, assist patients in looking for financial assistance from government and non-government sources to settle the unpaid hospital bills or medical expenses/ hospitalization expenses. Toward this end, the DOH shall work closely with financial institutions like, but not limited to, Philippine Health Insurance Corporation, Philippine Charity Sweepstakes Office, Philippine Amusement and Gaming Corporation, Local Government Units, as well as ,Congress, to provide funds for this purpose. d) All hospitals or medical clinics shall establish billing and collection procedures subject to current

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auditing

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regulations.

e) All hospitals or medical clinics shall have written policies and procedures for admitting and releasing patients, including identifying the officer/s or employee/s responsible for releasing patients. 2. Execution of Promissory Note

a) Except those who stay in private rooms, patients who are partially or fully recovered and who wish to leave the hospital or medical clinic but are incapable to pay, in part or in full, their hospital bills or medical expenses/ hospitalization expenses are obliged to execute a promissory note secured by either a mortgage, or a guarantee of a co-maker. b) In the case of a deceased patient, any of his surviving relatives is obliged to execute a promissory note secured by either a mortgage, or a guarantee of a co-maker. c) Hospitals or medical clinics shall have written policies and procedures for execution of promissory notes secured by either a mortgage, or a guarantee of a co-maker. 3. Penalty

Any officer or employee of a hospital or medical clinic responsible for releasing patients who has been found to commit any violation of R.A. No. 9439 and its implementing rules and regulations shall be punished by either a fine of not less than Twenty Thousand Pesos (P20,OOO) but not more than Fifty Thousand Pesos (P50,000), or imprisonment of not less than One (1) Month but not more than Six (6) months, or both such fine and imprisonment, at the discretion of the proper court. VI. Repealing/Separability Clause: Provisions from previous issuances that are inconsistent or contrary to the provisions of this Order are hereby rescinded and modified accordingly. If any provision of this Order is declared unauthorized or rendered invalid by any court of law or competent authority, those provisions not affected thereby shall remain valid and effective. R. A. No. 9439 repeals or amends the pertinent provisions of the Revised Penal Code, particularly Articles 267, 268 and 270, decrees, orders, rules and regulations inconsistent with the same, in so far as the same involves hospitals or medical clinics, medical practitioners, and their staff and employees. VII. Effectivity: This Order shall take effect fifteen (15) days after publication in a newspaper of general circulation. (Signed) FRANCISCO T. DUQUE, III, M.D. M.Sc. Secretary of Health

http://philrights.org/wp-content/uploads/2010/10/Healthcare-under-lock-and-key.pdf. bukidnon

We are all kept alive by the work of mans mind the individual minds that still retain the autonomy necessary to think and to judge. In medicinethe mind must be left free. Leonard Peikoff, Medicine: The Death of a Profession, Voice of Reason, 306. Republic Act 9439 or the Anti-Hospital Detention Law was signed by President Gloria Macapagal-Arroyo last April 27. Under this law, it would be:

unlawful for any hospital or medical clinic to detain or to otherwise cause, directly or indirectly the detention of patients who have fully recovered or partially recovered or have been adequately attended to or who may have died, for reasons of nonpayment in part or in full of hospital bills or medical expenses. (http://www.gov.ph/news/?i=17643). Patients who wanted to leave the hospital but arent capable of settling bills will now have the right to demand to be allowed to leave the hospital with corresponding medical certificate and pertinent discharge papers upon execution of a promissory note covering the unpaid obligation. The law was said to be not applicable to those who stayed in private rooms. While it may seem that this law could help those whore in need of medical care yet lack the finances, in turn, it actually directly transfers the burden of the unpaid expenses upon those who privately-own hospitals and indirectly to the hospital employees and other patrons of the hospital who diligently pay their bills. It is doubtful that the government will subsidize any of these unpaid expenses because it cannot even take care of its own government hospitals. In the Inquirer.net news last August 30, Private Hospitals Association of the Philippines (PHAP) said that its member-hospitals plan to hold a regular boycott or a hospital holiday every month during which, for a day or two, only emergency cases will be entertained and the hospitals will retain the right not to treat non-emergency cases, until 2008, if the government fails to repeal or come up with reasonable implementing rules and regulations. The aforementioned hospital holiday was supposed to be held last May but it was deferred after the health department invited the group to deliberate and formulate the IRR for R.A. 9439. But, according to PHAPs spokesperson, Dr. Rustico Jimenez: The [PHAP] board saw that the dialogues with government have led to nowhere. There were no positive actions to protect the hospitals. In the IRR, there is no protection for the hospitals from patients non-payment of bills (Inquirer.net). Senator Pia Cayetano, whos one of the principal sponsors of R.A. 9439 and the chair of the Senate committee on health and demography, appealed to the leaders of the PHAP to postpone the planned hospital holiday and committed that shes open to a dialogue on possible amendments to include specific provisions to protect their financial viability, since it will only aggravate the ongoing problem of healthcare and it is a disservice to the public (GMAnews.tv). Also, she assured hospital owners that the newly signed law has enough safeguards against abuses at the expense of private hospitals business. Health officials and members of the PHAP will then have a dialogue tomorrow, Wednesday.

I have heard of this Hospital detention law before but it was only tonight that I heard from the news that the law is still a little rough on the edges. And thats putting it mildly, Id say. I guess this is another crappy band-aid solution that the government has formulated in order to address the problem of unpaid hospital bills by those who are in financial constraint without having to actually contribute to the real solution, but instead, passing on the burden to the hospital business owners, healthcare professionals, and the hospital personnel. Many people will hate me in saying this but I believe that this Anti-hospital detention law is neither pro-poor or anti-poor. This law is actually detrimental to all of us, whether rich or poor. If R.A. 9439 will not be amended properly or scrapped all together, I think were going to see the slow, painful death of Philippine Healthcare. Why do I say so? Let me illustrate. It is unfortunate that our healthcare system is not very well-established. Even if there are government hospitals available, their number is not enough to support the needs of millions of poor Filipinos who cannot afford medical care in private hospitals. Overcrowding and lack of medicines and other medical supplies have always been an unsolved problem. Just walk through the emergency rooms of any government hospital, like Philippine General Hospital (PGH) or Jose Reyes Memorial Hospital, and youll know what I mean. Go up to the wards and youll weep at the sight of relatives having to ambubag their own dying patients because there arent enough mechanical ventilators. And the bed capacity of most government hospitals arent enough to cater to the actual number of in-patients that those whore the excess have to suffer being allocated to the corridors and even the basement. Visit Fabella Memorial Hospital and youll see how three pregnant women in labor have to share one bed stained with feces and urine. Its the same with the big ward halls, where two beds have to be put together so that it can accommodate 3 or 4 mothers and their babies and the place stank of lochia , blood, and sweat because there arent enough hospital personnel to clean the hall and the bathrooms. There are not even enough nurses and doctors to take care of these patients, as the government hospitals funds arent enough to hire more. So due to overcrowding in government hospitals and in cases wherein going to these hospitals can be troublesome and time-consuming, some patients do find themselves admitted in private hospitals, either in private rooms or in the charity ward. And while their medical problem is gradually being solved, a new problem arises how to pay the bills. In my experience as an emergency room physician, the hospital where I work usually have these patients who have financial constraints. And contrary to what notions others might have about private hospitals refusing patients who appear to have inability to pay, we dont refuse such

patients outright. For emergency cases, we stabilize such patients, doing what we could and then if already stable for transfer, advise the relatives to just transfer the patient to a government hospital if theyre concerned about finances. If the relatives would insist on being admitted in a private room or in the ward (but it isnt a charity ward. Rather, its just the most inexpensive room available in the hospital), then we do so. At least, they were given the options and theyll not have to think that they have been maltreated in any way. It is a misconception that all private hospitals detain their patients and maltreat them when they couldnt pay up. In fact, those who had to stay in the hospital for extended periods (for varied reasons like waiting for parents whore arriving from a far away place) are still treated as patients, with room and food. Theyre not locked up in dark, inhabitable places as media so often like to portray. If come billing time and theyre not capable of paying the cost of hospital treatment, then theyre allowed to sign promissory notes, in which they sign a document promising to pay a certain amount at a specified time. Note that these are legal documents. However, Dr. Jimenez is right in saying that in 10 promissory notes, only 1 is paid. When due time comes, no one from the patients family ever comes to the hospital to pay the amount due for that specified time. When someone from the hospital comes to the homes of these patients, theyre told to come back next time. And this becomes a horrendous cycle. Sometimes, the patient and the relatives leave and go back to their provinces so as to escape payment of the bills. And so, private hospitals do operate at a loss sometimes. Or nowadays, most of the time. And this is what most people do not understand. They have this notion that hospitals are rich institutions and that it wouldnt really hurt them if they take away from them a thousand pesos or more worth of hospital payment. Why would it hurt them? They, who earn so much? Also, some people just have the notion that all capitalists are just crooks and that by taking from them, theyre only taking back what they have taken from other poor people. While that it is understandable that some people would think that way, it doesnt equate to being correct or being justified. Why bear such hatred against all capitalists when they generate muchneeded jobs? Why only see them as greedy businessmen? Dont they have the right to be compensated? What is wrong with these businessmen having and wanting money? Nothing. And Ill tell you why. Lets go back to the hospital situation cited above. So, there are unpaid expenses and to whom the burden is passed? Since the hospital have less earnings, it will either delay the salaries of the personnel, cut back on other expenses by buying cheaper medicines or medical supplies,

increase consultation fees, or worst, to lay-off some workers. Most of the private hospitals nowadays are understaffed, moreso the smaller ones. If it continues long enough, these hospitals will just close down. How can anyone withstand an operation of business at a loss for a long time, as the government is expecting the private hospitals to do, in the name of service to humanity? I believe were already experiencing the effect of this and, if R.A. 9439 doesnt get amended, were yet to see the worse. So, you see, its not only the hospital owner who is affected by such unpaid expenses. I hope people will not think that theyre only taking from the rich hospital owner or the stockholders. By not fulfilling promises and not paying their bills, theyre also taking from those who, like them, are workers trying to survive the hard life we have right now. It is never justified to demand for something that you havent worked for or earned. The government cannot simply pull the belt a notch tighter on the hospitals and the healthcare practitioners, as it wont to do. While that we all have the right to access healthcare, it is not in the expense of trampling over other peoples right that we should do so. While that it is important to address the problem of the public healthcare, the government should also recognize this problem cannot be solved by trampling upon the rights of healthcare practitioners. We, the healthcare professionals are human beings, too, and we have our rights, too. We strive for both survival and fulfillment, just like any other citizen. While that we vowed to serve humanity, we are not humanitys slaves. If the government continues to formulate temporary solutions for deeply-rooted problems, such as the deteriorating health care of the country, and would arrogantly show that theyre more inclined to take the populist view, regardless if its right or wrong, then soon maybe the doctors will go on strike. Also, the government may be forgetting that, even if it can control the practice of medicine, it cannot force the practice of medicine on those wholl refuse to practice it anymore. To quote Dr. Hendricks in Ayn Rands novel, Atlas Shrugged: Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents itand still less safe, if he is the sort who doesnt.

Republic Act 9439 (the Hospital Detention Law) somehow provides temporary relief for poor patients who could be illegally detained in hospitals because of unpaid bills. But it failed to address the very reason poor patients are forced to go to charity wards in private hospitals.

People these days can hardly rely on public health services because even public hospitals now charge patients (who are mostly indigent) many fees: emergency room fee, out-patient department fee, operating room fee, etc. Moreover, many public hospitals are forced to admit patients twice or thrice their actual capacity. Overcrowded rooms and beds force many poor patients to go to the charity wards of private hospitals.

The government missed the nails head when it criticized and pledged to punish private hospitals that detain patients. There is truth in the claim of the Private Hospitals Association of the Philippines (PHAP) that only one in every 10 patients who sign a promissory note actually returns to settle his debt to the hospital.

With RA 9439, what President Gloria Macapagal-Arroyo did was tantamount to merely bandaging the wound instead of diagnosing the cause. It placed the blame on private hospitals instead of establishing an accessible health care system by allotting sufficient funds for public hospitals and facilities.

In fact, for 2007, the health care system has been given only 0.1 percent or a little over P11.5 billion out of the national budget of P1.126 trillion. This means each of the 80 million Filipinos has been allotted only P144.53 in medical services and medicines for the entire year! That is, if they get any medical treatment and medicine at all. Meanwhile, debt servicing continues to get a large slab of the pie with P318.18 billion or 28 percent of the budget.

As long as the government remains indifferent to the peoples needs, it is apt for Filipinos to strive to gain access to quality health care services.

The newly elected officials, on the other hand, should heed the call for the government to respond to peoples needs and welfare.

ELEANOR JARA, MD, executive director, MERRY MIA, MD, director, Health Education Training and Services Council for Health and Development (CHD), 19 Scout Borromeo St., South Triangle, Quezon City