Overseas Medicare Coverage for US Citizens While in the Philippines

Overseas Medicare Coverage for US Citizens while in the Philippines

Summary

Abraham T. Rasul, Jr., M.D. President Elect, Philippine Medical Association of Metropolitan Washington DC President Elect, University of the Philippines College of Medicine Mu Sigma Phi Foundation USA 1160 Varnum Street, NE #008 Washington DC 20017 (202) 997-6833. (202) 526-0099

There had been several attempts by various Filipino American groups to lobby the US government to change the Medicare rules to allow for coverage of medical care of Filipino Americans while they are in the Philippines. Unfortunately there had been no success. It is extremely difficult to change this federal program without any evidence that existing medical care in the Philippines is comparable to the US. There are no studies to date that compare outcomes in the two countries.

As of now, Medicare will only pay for medical care for Medicare beneficiaries from Guam requiring emergency care while they are in the Philippines. The main reason is proximity of the health care facility rather than economic costs, the Philippines being closer to Guam than the US mainland. This is also true for US citizens requiring medical care while traveling through Mexico or Canada. In these cases, providers and facilities are not required to submit claims for payment of services. Patients will have to pay for services and submit to Medicare the claims for reimbursement of health services which they had already paid for. Patients will have to get all the required documentation for reimbursement. Hopefully, documentation or proof of rendered services meets the Medicare standard for documentation.

There is no question that the costs of medical care in the Philippines are significantly lower than in the US by an average of 25-30% of cost of care. A similar study arguing on behalf of Mexico Medicare coverage also cites a similar figure.

The 2010 census had 13.2 million Asian Americans, with 2.377 million Filipino Americans (one race listed by respondents). We do not have a breakdown for age yet at this time. Using the 2008 data, Asian Americans 65 and older account for 9.7% of the group. Using this number, then we probably have about 230,000 Filipino Americans 65 and older who are registered in the census. The number is probably greater since we also have younger Medicare beneficiaries who are disabled or have chronic diseases. The 2010 Medicare data listed over 38 million beneficiaries who are 65 and older, but the total population is over 47 million. This is due to the addition of the younger disabled Medicare population.

The most common procedure paid by Medicare in 2008 was a routine follow up doctor’s visit (99214). Medicare paid over six billion dollars for this alone- $6,031,239,662 for 68,634,223 office visits or $87.87 per visit. A similar visit in the Philippines would cost between P500 or around $10-15. The savings from this visit alone is up to $77. Also in 2008 the initial comprehensive doctor’s evaluations/visits cost Medicare $447 million for 3.2 million visits, an average of $135/visit. In the Philippines, it would cost around P1000 or $20-25. The savings here is up to $115.

Let’s say the 230K Filipino Americans are all Medicare beneficiaries and half of them, 115,000 went home and had a medical evaluation and then a subsequent follow up visit before returning to the US. The savings from these 2 visits alone would be $192/person. The total savings then would be over $22 million. They have not undergone tests or treatment yet. And this is just on one trip.

These are just the most common CPT or procedure codes paid by Medicare. An open heart surgery could cost up to P1 million or around $25,000 in the Philippines. In the US it would be about 4x more expensive. The savings add up whenever Filipino American patients have their medically necessary tests and treatment done in the Philippines. The costs of non medical care including available family support is also a valuable unknown that was never figured in the total costs.

It is not unrealistic therefore to expect the US government and Medicare savings in billions of dollars every year for medically necessary treatment of Filipino American Medicare beneficiaries.

The savings from the Philippine Overseas Medicare program will help Medicare sustain its growth as well as help the US economy with its huge budget deficit.

The Medicare patient population is now global. These US citizens are entitled to care that should be covered by Medicare. They had paid into this federal program during their productive years. With the escalating and unsustainable costs of health care, looking at more affordable and yet quality care meeting Medicare standards will help reduce this burden.

Objections to extending overseas Medicare coverage and arguments against them. The main objection to extending Medicare coverage overseas would be the lack of studies that support the claim that Philippine medical care complies with the standard of care demanded by Medicare. This is an unknown that works against attempts to extend overseas coverage.

Another objection would be the lack of patient protection rights. This can be fixed by Philippine legislation however.

But there has to be a valid study to compare outcomes of treatment in both countries. There has been no attempt so far. This is the basis for a prospective pilot study.

There are some who argue that extending overseas Medicare coverage will take away health care related jobs from US citizens. But this is not the case. There will be jobs creation if Medicare extends overseas coverage. There will be a need to train medical billers, coders and other related personnel to tackle billing and reimbursement issues.

A fiscal intermediary needs to be established. This financial entity will be responsible for the credentialing of providers and facilities as well as screening and paying for costs of care. This will create more jobs for US citizens.

Rationale for a prospective pilot study A 2 year study will allow us the opportunity to gather data regarding costs of care and outcomes of treatment and compare it with US studies. While there is no question that costs of care will work to our benefit, we still have to document actual outcomes of treatment including complication rates as well as patient satisfaction surveys.

There will always be justifiable questions regarding standards of care as well as level of medical expertise. To eliminate variables in this study, only medical facilities accredited by the Joint Commission International (JCI) will be included in the study. Major medical centers like Asian Hospital Medical Center, St. Luke’s Hospital, and Medical City are a few of these facilities.

The question of level of medical expertise and skill can be resolved by including only providers who have US training or comparable skills. There is no doubt that Foreign Medical Graduates provide exemplary care in US medical facilities. These foreign medical graduates are also responsible for training US medical graduates.

It is only after we complete this pilot study and show positive and productive outcomes will the US Congress have the basis to change the Medicare program and extend overseas coverage in the Philippines. Short of this, any attempts will be futile. A 2 Year Prospective Pilot Study (Demonstration Project) Methodology Inclusion criteria: A limited study involving medical facilities accredited by the Joint Commission International (JCI).

Providers with US training or comparable credentials will be included in the study. This will limit variables in skill and care compared to their US counterparts.

Limited medical diagnoses (ICD-9 codes) Limited procedures (CPT codes)

Examples: Medical treatment of hypertension. Chest pain, coronary artery disease treated with medical management or placement of cardiac stents. Joint pain treated with medical management or arthroscopic surgery.

Time Frame of study 1st Year Accreditation and credentialing of facilities and providers Training seminars: Medical documentation and Coding. Reimbursement Review of HIPAA (Health Information Portability and Accountability Act) Patient Enrollment. Community Awareness Program.

Identify the Fiscal Intermediary responsible for Reimbursement: Guam or Washington DC /Maryland /Virginia fiscal intermediary (Highmark System)

2nd Year Start Billing and Reimbursement

Quarterly Reviews- Documentation and Coding Issues. Patient treatment reviews.

Fraud Prevention

Review and Conclusion of Study

Analysis and Recommendations Creation of a Task Force for Overseas Medicare Coverage

A body composed of health care experts knowledgeable with US Medicare requirements will be responsible to undertake this prospective study

Educating the Filipino American community in terms of Medicare regulations as well as medically necessary care will be an important function of this task force. Physician provider education in the Philippines in terms of appropriate documentation, patient privacy and protection regulations need to be established.

Rates of reimbursement for medically necessary care have to be established.

This body will complete the study within 3 years and submit its recommendation.