ORIGINAL ARTICLE

Healthcare-associated Expenses Due to Injuries

in the Philippines
Adovich S. Rivera,1 Hilton Y. Lam,1 Joel U. Macalino2 and Jose D. Quebral3
1
Institute of Health Policy and Development Studies, National Institutes of Health, University of the Philippines Manila
2
Department of Surgery, College of Medicine and Philippine General Hospital, University of the Philippines Manila
3
Department of Surgery, University of the East – Ramon Magsaysay Memorial Medical Center, Manila, Philippines

ABSTRACT

Background. Injuries are common causes of hospital visits and deaths in the Philippines. The national healthcare-
associated expenses due to these injuries have not been established.

Objective. To estimate the healthcare-associated expenses due to injuries in the Philippines.

Methods. Review of patient charts and patient interviews were conducted in 21 hospitals in the Philippines.
A convenience sample of patients was interviewed to ascertain other direct medical and non-medical expenses.

Results. Median admission costs based on hospital bills were: road injuries: PhP10,192.25, poisoning: PhP4,402.00,
burns: PhP6,521.53, animal-related: PhP5,105.92, other accidents: PhP7,545.71 and intentional injuries:
PhP8,023.00. Based on survey, other expenses not stated in hospital bills include medical supplies (PhP4,000.00),
diagnostic tests (PhP 2,000.00), and post-discharge expenses (PhP 1,000.00).

Conclusion. Expenses due to injuries varied according to cause. Admission expenses recorded in the bill were not
the only healthcare-related expenses shouldered by the patient and accounted for 68.6-159.0% of the bill value.

Key Words: healthcare expense, injury, Philippines, trauma

Introduction

Injuries are one of the most common causes of disabilities

and premature deaths in the world. Unintentional injuries,
transport injuries, self-harm, violence, and injuries from war
and disasters are in the top 20 causes of disability-adjusted life
years lost in 2010.1 It is seen to disproportionately affect low to
middle income countries. For example, in the Western Pacific
Region, injury-related mortality rates are 78.4 per 100,000 in
low-middle income countries (LMIC) compared to 56.2 per
100,000 in high income countries within that region.2
Injuries (or external causes of mortality) are in the top
ten causes of registered deaths in the Philippines.3 The Online
National Electronic Injury Surveillance System (ONEISS)
reports 10,000 to 11,000 injuries per quarter. These results
managed by the Department of Health likely represents only
the tip of the iceberg as the surveillance is present in only a
limited number of hospitals and reporting is not complete.4-7
Corresponding author: Adovich S. Rivera, MD The Global Burden of Disease (GBD) group has estimated
Institute of Health Policy and Development Studies that the Philippines lost 2.4 to 2.9 million disability-adjusted
National Institutes of Health
University of the Philippines Manila
life years (DALYs) due to injuries in 2015.1
Contact number: +63 917 5324607 Injury is defined by the World Health Organization
Email: adovich.rivera@gmail.com as “the physical damage that results when a human body is

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Healthcare-associated Expenses due to Injuries

suddenly or briefly subjected to intolerable levels of energy.”8 emergency room (ER) only patients were targeted to be
In hospitals, the International Classification of Disease (ICD) reviewed. Charts were selected by generating a list of random
Code 10 may be used with injury diagnosis corresponding to dates then sampling one chart per injury category per date.
codes from V00 to Y99 and those under S00 to T88.9 The Classification according to injury category was done based
ONEISS also describes several injury categories identified by on the diagnosis written in admission or emergency room
the Department of Health. logbooks. A chart was included if the diagnosis contained a
The healthcare-associated expenses due to these injuries reference to any injury category written above or described by
have not been established. The Philippine Health Insurance ONEISS. This was used since ICD 10 codes were not written
Corporation (Philhealth) has set the amount of PhP9,000 in logbooks. Once charts were retrieved, clinical data were
as payment for admitted cases of injuries. One study has extracted. If upon review, a sampled chart was determined to
attempted to estimate the healthcare-associated expenses be from a non-injury admission, the chart was replaced. Billing
of injuries in the Philippines but it was limited only to road statements were also requested and expenses were extracted.
traffic injuries. The study estimated that “minor injuries” cost For the patient survey, a convenience sample of 423
PhP3,957, “serious injuries” cost PhP88,530 and fatal injuries patients previously seen for injuries from 1 January 2014 to 30
cost PhP63,159. This was limited to two urban training June 2016 was recruited. Recruiters approached individuals
institutions and there was no definition provided for classifying who were consulting at the outpatient or emergency
injuries between serious and minor.10 Thus, the objective of departments, or who were admitted in the facility and were
this study was to estimate the healthcare-associated expenses invited to join the study. If invited individuals agreed, phone
due to various categories of injuries in the Philippines. interviews were conducted regarding the injury and the
associated healthcare costs.
Method Standard forms were used. Data were encoded in
Microsoft (MS) Access. Data cleaning was done in MS Excel.
This was a cross-sectional study using two methods: Analysis was conducted using Stata 12. The protocol for this
records review and patient interviews. Injuries were grouped study was reviewed by the University of the Philippines (UP)
into six categories based on cause: Manila Ethics Review Board as well as by accredited review
a. Road traffic injury (RTI) boards of participating health facilities.
b. Mechanical accidental trauma
c. Mechanical intentional trauma Results
d. Burns and blast injury
e. Poisoning Cost of Admitted Cases
f. Animal-related injury. Charts of 1,853 admitted and 1,976 ER only cases
Twenty-five hospitals (21 government and 4 private) were reviewed. The average ages for each sex and category
agreed to participate in the study. At least two hospitals ranged from 16.9 to 31.8 years. Burn victims and poisoning
were invited each from Luzon, Visayas, Mindanao and the victims had noticeably lower average ages compared to other
National Capital Region (NCR) for inclusion in the study. categories. Average ages of burn victims were 21.8 years for
Hospitals with the largest authorized bed capacities in urban male and 16.9 for females. Poisoning victims, on average,
areas were first recruited followed by selection of hospitals were 24.8 years for males and 20.7 years for females. Patients
located in rural areas near the participating urban facilities. A in the other categories had average ages ranging from the late
random sample of cases due to injuries which were seen from 1 20s to the early 30s. (Table 1).
January 2014 to 31 December 2014 was retrieved. The sample Of the 1,853 admitted cases, 1,482 had available bills. To
size targets were computed assuming a variance of 1,000 at obtain a single value for average cost of an injury, an average
alpha of 0.05 and margin of error of 5%. The number of charts value was computed by applying weights to the obtained
per facility was then proportionately distributed across the average cost per category. Weights were obtained from the
participating hospitals based on authorized bed capacity. In distribution of injuries reported in the ONEISS 2014. The
each hospital, an equal number of charts of admitted and weighted average cost of injury was PhP8,479.69.

Table 1. Sex and average age of patients seen due to injuries in 21 hospitals
Male Female
Category
n Average Age SD   n Average Age SD
Road Traffic Injury 999 28.8 15.99 333 27.8 19.19
Mechanical Accidental Trauma 497 27.9 19.35 187 31.5 27.48
Mechanical Intentional Trauma 418 30.4 14.10 89 31.8 16.38
Poisoning 242 24.8 18.70 141 20.7 17.84
Burns and Blast Injuries 289 21.8 17.81 138 16.9 19.01
Animal-related Injuries 225 26.5 19.56 189 28.7 22.25
Total/Weighted Averages 2,670 27.6 17.33   1,077 26.6 21.55

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Table 2. Gross Bill of Injury Patients According to Injury Category Based on Chart Review
A. Admitted n Average SD Median Min Max
Road Traffic Injury 608 20,665.87 33,409.80 10,192.25 360.00 352,202.60
Mechanical Accidental Trauma 269 17,713.08 27,861.58 7,545.71 382.00 164,295.00
Mechanical Intentional Trauma 180 17,638.07 24,614.82 8,023.00 500.00 165,448.80
Poisoning 178 5,771.88 5,938.73 4,402.00 345.50 50,069.40
Burns and Blast Injuries 185 14,258.90 22,547.84 6,521.53 552.60 206,358.00
Animal-related Injuries 62 7,102.14 7,742.22 5,105.92 800.00 40,391.50
B. ER only n Average SD Median Min Max
Road Traffic Injury 150 899.23 1,339.69 450.00 50.00 8,546.40
Mechanical Accidental Trauma 22 731.44 1,176.27 183.90 6.66 3,724.00
Mechanical Intentional Trauma 42 395.98 722.82 197.65 24.00 3,607.50
Poisoning 15 699.20 987.95 265.00 100.00 3,055.00
Burns and Blast Injuries 12 390.04 803.77 114.50 67.00 2,915.00
Animal-related Injuries 13 192.00 161.66 169.00 30.00 668.00

Table 3. Comparison of Gross Bill and OOP Across Different Injury Categories of Admitted Patients
Gross Bill OOP Expenses
Category  n
Average Median Average Median
Road Traffic Injury 529 21,109.24 10,452.88 7,665.87 1,910.50
Mechanical Accidental Trauma 155 5,943.62 4,413.70 1,624.90 207.00
Mechanical Intentional Trauma 172 15,096.80 6,662.06 3,489.87 625.00
Poisoning 59 7,354.49 5,225.00 1,751.89 0.00
Burns and Blast Injuries 237 17,949.34 8,055.00 7,225.74 1,140.00
Animal-related Injuries 157 17,563.43 8,599.00 6,541.18 1,064.00

The average and median gross bills of the different injury t = 2.3120, p = 0.0227). Medians were also higher in private
categories were also computed. Median was presented due to hospitals compared to government at PhP12,381.35 and
skewed data. RTI had the highest average (PhP20,665.87) PhP4,358.95, respectively.
and median (PhP10,192.25) costs while the lowest average The average bills and out-of-pocket expenses according
(PhP5,771.88) and median (PhP4,402.00) costs were to area (NCR, Luzon, Visayas, and Mindanao) were also
poisoning cases. (Table 2A). obtained and compared. One-way ANOVA detected a
A sub-analysis of comparing out-of-pocket (OOP) difference in the averages of both bills and OOP expenses. Post
expenses as reported in the bill and the gross bill was done hoc tests showed the average bill in NCR was significantly
for admitted individuals with available bills and OOP different compared to Mindanao and that the OOP expenses
information. The median OOP ranged from zero for in the NCR were significantly different compared to all other
animal-related injuries to PhP1,404.50 for RTI. In all injury areas. No other pair-wise comparisons were significantly
categories, the median OOP expenses were lower than the different. (Table 5).
gross bill. (Table 3).
Another sub-analysis for average and median expenses Cost of ER only cases
according to the GBD injury categories were computed. Since Only 254 ER bills (out of 1,976 cases) were retrieved as
there were numerous categories, cost data of only those with many hospitals did not keep billing statements of ER patients.
30 or higher number of cases were analyzed and presented. Overall, the average cost of an ER only case was PhP729.42
The injuries with the highest median cost were abdominal (SD = 1,181.43) and the median was PhP269.00. Weighted
injuries at PhP27,318.25 while the lowest median cost was average cost of injury seen at the ER was PhP262.53.
for poisoning at PhP4,425.00. (Table 4A). There was some variation in the average depending on
Healthcare costs of the cases admitted at private hospitals the injury category. RTI had the highest average (PhP899.23)
were found to be higher than those of government cases. and median (PhP450.00) costs while burn injuries had the
The average and median bills for private cases (n = 94) were lowest average (PhP390.04) and median (PhP114.50) costs.
PhP23,073.06 and PhP12,381.35 while those of government (Table 2B).
hospitals (n = 1,397) were on average PhP16,345.36 with a Costs of selected GBD categories seen at the ER only
median of PhP7,285.00. However, the difference between were also computed. The median cost of the most common
averages was not statistically significant using Welch t-test type, open wounds, was PhP220 while the next most
(df = 100.282, t = 1.8167, p = 0.0722). The average OOP common, sprains and strains, had a median cost of PhP530.
expenses was significantly higher in private hospitals at (Table 4B).
PhP10,206.61 (SD = PhP18,428.80) compared to government Due to the limited sample, costing of common conditions
hospitals at PhP5,596.70 (SD = 532.93) (df = 105.812, were done with key informants from health facilities.

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Table 4. Average and Median Cost of Selected GBD Injury Types Based on Charts Reviewed
Injury Type Count Average SD Median Min Max
A. Admitted
Open wound(s) 229 10,185.35 15,292.75 5,812.50 360 156,866.00
Minor TBI 216 10,237.80 18,402.37 6,772.00 857 241,323.00
Poisoning requiring urgent care 179 5,716.06 6,016.27 4,392.85 345.5 50,069.40
Mod-Severe TBI 161 23,641.72 38,526.36 11,277.50 880 336,561.00
Burns, <20% total burned surface area 106 8,026.83 10,558.14 5,431.50 552.6 68,385.00
Leg fracture 80 27,415.45 31,255.78 17,974.00 461 156,493.00
Thigh fracture 63 25,755.34 24,958.10 16,174.55 1350 99,936.75
Internal hemorrhage in abdomen and pelvis 60 35,355.66 32,415.75 27,075.90 1800 165,448.80
Burns, >=20% 50 19,895.19 18,326.68 13,358.67 921 70,976.00
Forearm fracture 46 18,339.85 27,454.74 8,342.48 972 153,784.90
Sprain and strain 40 12,137.83 19,440.65 5,886.10 400 91,858.79
Severe chest Injury 38 25,526.44 32,468.19 12,442.50 1750 159,049.20
Shoulder/Arm Fracture 30 19,953.19 32,862.34 13,246.62 571 182,139.90
B. ER only
Open wound(s) 145 644.09 967.43 220.00 24.00 4,795.94
Sprain and strain 28 1,169.84 1,840.25 530.00 6.66 8,546.40
Contusion 19 334.12 271.54 226.15 48.00 930.00
Poisoning requiring urgent care 16 888.25 1,217.71 277.50 100.00 3,724.00
Burns, <20% total burned surface area 8 158.64 133.97 114.50 67.00 482.50

Table 5. Average reported bills and OOP expenses of admitted patients according to area
  Gross Bill OOP Expenses
  n Average SD n Average SD
NCR 151 20,483.97 41,738.73 122 16,020.62 38,426.59
Luzon 504 15,955.90 28,602.29 431 7,221.64 20,731.93
Visayas 429 16,055.64 22,654.66 388 4,039.68 11,961.68
Mindanao 398 16,551.31 24,609.82 368 3,031.93 6,716.20

Based on the costing done, the cost for open wounds ranged SD: 14,865.80) and median of PhP0.00 for admitted patients
from PhP180 to 1,300 if no suturing was done and increased and an average of PhP2,332.81 (n = 95, SD: 11,669.91) and
to PhP320-1,900 if with suturing. Fractures treated at the median of PhP100.00 for ER only patients.
ER would cost from PhP690 to 3,200. Other conditions with Sixty-three percent (63.0%) of admitted cases (n = 262)
cost estimates were bites (PhP230-2,000), traumatic brain and 40.4% of ER cases (n = 161) were seen in other hospitals
injury (PhP380-8,200), burns (PhP230-2,000) and alcohol prior to the study hospital. The number of additional
intoxication (PhP30-1,130). facilities prior to the study site was 1.21 (SD: 0.69) among
admitted cases and 1.12 (SD: 0.33) among ER only cases.
Patient survey The average and median OOP of admitted patients (n = 134)
Four hundred twenty-three (423) patients were in these other facilities was PhP13,520.61 (SD: 46,322.85)
successfully followed-up and interviewed in 15 study and PhP730.00. For ER only patients (n = 67), the average
hospitals. Almost 70% were males and the average age was and median values were PhP3,571.27 (SD: 24,301.81) and
29.07 years (SD: 17.79). Sixty-one percent (61.6%) of the PhP0.00.
respondents were admitted in a study hospital. Majority of Around half of admitted patients (45.8% or 120) reported
the respondents were RTI victims; other respondents were receiving donations or financial assistance for their care. The
distributed as follows: mechanical accidental trauma: 26.5%; average amount was PhP20,414.35 (n = 115, SD: 43,659.69)
animal-related injuries: 17.26%; mechanical intentional with a median value of PhP5,000.00. In contrast, around a
trauma: 9.22%; burn: 3.31%; and poisoning: 2.36%. The quarter (23.0% or 37) of ER only patients received financial
data were analyzed as a whole due to the limited number assistance with an average amount at PhP 5,941.89 (n = 37,
of respondents. SD: 11,130.93) and a median of PhP 2,000.00.
For expenses in the study site of recruitment, the average In terms of costs not reflected in the bill, there were
reported bill of admitted patients was at PhP34,733.01 two types: treatment-related and non-treatment related.
(n = 134, SD: 58,517.25) with a median of PhP20,000.00. Treatment-related included medicines, medical supplies,
Among ER patients, the average was PhP4,271.98 (n = 121, and diagnostic tests done outside the health facility. Non-
SD: 16,584.21) with a median of PhP 500.00. The OOP was treatment-related expenses included food, transportation,
lower in both groups at an average of PhP7,487.99 (n = 189, and other expenses (e.g. toiletries, etc).

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Among admitted patients, 56.9% or 149 had to pay for (n = 54, SD: 2,623.95) with a median of PhP512.50. The
medicines or medical supplies not reflected in the hospital average reported interest of the loans was 9.22% (n = 66, SD:
bill. The average and median cost of these items were 13.77) with a median of 6.00%.
PhP11,276.47 (n = 141, SD: 21,511.99) and PhP4,000.00, Patients were asked if they experienced any mental
respectively. In the same group, 11.8% or 31 had to pay health problems due to the injury. Majority (69.9%) of
for diagnostic tests done outside the facility, at an average admitted patients said yes while almost half (47.2%) of
of PhP4,451.38 (n = 29, SD: 7,569.75) and median of the ER patients said yes. They were also asked if this led to
PhP2,000.00. missing work days and this occurred in 20.61% of admitted
Meanwhile among those treated at the ER setting only, patients and 6.21% among ER patients. Despite these, only
46.0% or 74 had to pay for medicines or medical supplies not 4 cases consulted for mental health services.
reflected in the study site bill and 10.6% or 17 had to pay
for diagnostic tests not reflected on the bill. The average and Discussion
median cost of the extra supplies were PhP2,973.26 (n = 70,
SD: 7,596.224) and PhP750.00, respectively. The average and This is the first comprehensive national study to estimate
median cost of the laboratory tests were PhP1,959.29 (n = 14, the healthcare-associated costs due to various causes of
SD: 2,561.78) and PhP1,025.00. injuries in the Philippines. The study collected data from
The average and median non-treatment-related multiple hospitals in various provinces. It demonstrated that
expenses of admitted patients were PhP5,589.76 (n = 253, actual out-of-pocket expenses of patients due to injuries
SD: 7,775.00) and PhP4,040.00. For ER patients, the value were much lower than the bills charged to them partially
was at PhP561.46 (n = 146, SD: 1,840.84) and PhP73.00. due to the coverage by the national health insurance system
Median food expenses were PhP2,430.00 for admitted and and through the no balance billing policy. Patients, however,
PhP0.00 for ER patients. Median transportation expenses reported needing to buy supplies or medicines or pay for
were PhP349.00 for admitted and PhP58.00 for ER patients. services that were not reflected in the bill. These costs
These expenses included those for the bantay or carer such as were not reported in the bill since these are not available
their food and the travel to and from home to facility. in the hospital. This stresses the need to include patient
There were also post-discharge costs which included interviews when conducting healthcare costing studies in the
follow-up, transportation, medicines and supplies, and Philippines. Patients also spent an additional PhP2,000.00
rehabilitation. Follow-up was done by 69.6% of admitted post-discharge. This value could be higher if they would
patients and 62.7% of ER only patients. The average number need rehabilitation services or diagnostic tests or a second
of follow-ups were 2.28 (n = 166, SD: 2.19) for admitted admission for definitive treatment. Other healthcare-related
patients and 2.44 (n = 81, SD: 1.43) for ER patients. The expenses documented due to injuries were travel to health
price of follow-up ranged from PhP0.00 to 2,000.00 with facilities, missing days of work, and obtaining loans.
an average of PhP246.49 (n = 247, SD: 978.92); the median This study resulted in much lower values compared to the
was PhP0.00. The duration spent to do follow-up check-ups expenses reported by De Leon, Cal and Sigua but match the
including travel and wait times ranged from 20 minutes to Philhealth case rate for injuries which is set at PhP8,000.00.10
21 hours with an average of 4.98 hours (n = 247, SD: 3.59). One factor is that this study included hospitals in both urban
Transportation fees from home to follow-up ranged from and rural settings and did not limit to tertiary hospitals only;
Php0.00 to 6,000.00 with an average of PhP178.86 and a De Leon, Cal and Sigua only included two tertiary hospitals
median of PhP76.00. in Metro Manila. The sample also included more injury types
Post-discharge medicines and supplies for admitted and not just road injury types. Hospitals in certain areas also
patients were PhP2,406.98 on average (n = 243, SD: 4,751.79) have limited capacities to provide services (e.g. no CT scan in
with a median of PhP1,000.00. For ER only patients, the the hospital) and thus result in lower costs. The cases sampled
average was PhP835.84 (n = 156, SD: 2,944.193) with a were also first admissions of the patients. Some patients got
median of PhP0.00. For post-discharge diagnostic tests, the discharged without receiving definitive treatment such as
average expenses were PhP525.53 (n = 102, SD: 2,366.33) surgery leading to lower costs.
for admitted patients and PhP52.59 (n = 56, SD: 207.04) However, these costs validate the current rates provided
for ER only patients. Median values in both cases were at by the national insurance for injuries since the median cost is
PhP0.00. There were only 21 patients who reported utilizing close to the capitation value. Injuries are a very heterogeneous
rehabilitation services. The average cost of rehabilitation group as evidenced by the different median costs depending
services was PhP2,299.29 (n = 21, SD: 5,812.50). There were on the most severe form of injury experienced by the patient.
also 23 patients who were re-hospitalized but none were able For example, open wounds such as stab wounds in extremities
to report the cost of their re-hospitalization. or cuts cost PhP10,000.00 compared to thigh fractures, which
Around a third (31.0%) of ER only patients and half cost PhP25,000.00.
(53.5%) of admitted patients reported securing a loan due to This study used billing statements by hospitals and may
the injury. The average amount of the loans was PhP1,657.20 not necessarily be equivalent to the true cost of the injury

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Healthcare-associated Expenses due to Injuries

especially in terms of cost from the hospital’s perspective. costs exceeding Philhealth reimbursements will be shouldered
Several hospitals do not charge patients for emergency by hospitals which already have limited operating expenses. If
department visits; hence, there was limited data on billing these do not occur, hospitals will have more funds to allocate
statements of ER patients and ER only data does not reflect for other cases they cater. Fewer admissions due to injuries
the true cost. An alternative costing approach was done to will also allow freeing up more funds of the national health
estimate the value of these expenses. The method yielded wide insurance program that can be allocated to other diseases.
ranges of cost estimates. This was likely due to the variability
of the availability of tests and medicines in the facility. For Acknowledgments
example, some do not have CT scan machines hence the This study was funded by the Department of Health
treatment of brain injury would cost less. through the Essential Non-communicable Diseases Office.
The patient survey suffered from a low response rate and The group would like to thank the participating hospitals and
utilized a convenience sample which limits its generalizability. would like to acknowledge the invaluable contributions of
The assumption for variance was also too low which implies research assistants and data collectors of the study.
a need for a bigger sample size to obtain more precise
measurements. The results should thus be interpreted as Statement of Authorship
baseline data to guide future studies. Despite this limitation, All authors approved the final version submitted.
we observed that there are additional expenses not listed
in the bill in majority of patients. A prospective study can Author Disclosure
address this generalizability issue. All authors declared no conflict of interest.
Another factor affecting generalizability is the low
participation of private hospitals in this study as well as non-
Funding Source
random selection of health facilities. The dataset suggests that
This study was funded by the Department of Health
the median bill in private hospitals is almost two times higher
through the Essential Non-communicable Diseases Office.
than that of government hospitals although the averages
were not significantly different. The ideal scenario would be
to include a number private hospitals in accordance with the
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