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Experts Suggest Health Reform Adjustments

Fine tuning health reform to end abuses will increase efficiency, those without previous access to healthcare will be more costly at first


August 3, 2000
Copyright © 2000 CARIBBEAN BUSINESS. All Rights Reserved.

The health reform is here to stay, most experts agree. They also think, however, that it ought to be improved.

Among the principal recommendations they propose to improve the health reform are reducing region size to comprise fewer cardholders per region, establishing a clearinghouse to check the use of multiple health plans by the same person, and limiting the freedom to choose drugstores, dentists, laboratories, and specialists or, alternatively, to set a capitation on each of these services.

Capitation is the money allocated by health insurers per patient to cover all health costs, an average of $64 monthly.

Triple-S Inc. President Miguel Vazquez Deynes suggests that health regions should be broken down to include 70,000 to 75,000 cardholders, rather than the 200,000 to 270,000 patients now comprised per region. Triple-S is the No. 1 local health insurer, with the largest number of health reform patients (690,000).

He also recommends that health insurance companies complying with parameters set by the Health Insurance Administration (ASES by its Spanish acronym)—which oversees the reform’s implementation—and presenting cost increases that aren’t higher than the rate of inflation should retain their regions indefinitely.

At present, an annual contract-bidding process determines the assignment of health insurers to regions.

For his part, Joaquin Rodriguez, co-founder and chairman of Caguas’ Hospital Interamericano de Medicina Avanzada (HIMA) endorses the idea of retaining as many health insurers as possible because "each health insurer has its own set of rules which may vary completely with the procedures of the former health insurer or of the one that follows."

For example, a new health insurer assigned to Caguas two years ago offered patients total freedom of pharmacy selection. "This resulted in our firing 300 persons—mostly messengers and drugstore personnel that provided immediate service. We’d give patients enough medicine on their first visit to cover that day. Then, we would deliver the remainder of the prescription in 24 hours," Rodriguez said.

The large volume HIMA bought from pharmaceutical companies earned them hefty discounts, according to Rodriguez.

Vazquez Deynes noted that before the health reform, the government bought large quantities of medicine for its hospitals as well as its diagnostic and treatment centers (CDT by its Spanish acronym) and it also got large discounts—as much as 40%. Similar discounts are not available to health insurers, he said, adding that Walgreens and El Amal are dispensing 70% of health-reform prescriptions.

The total freedom allowed cardholders is causing havoc among health providers.

Rodriguez suggested health-reform patients be required to return to the same group of primary physicians they first go to for at least a year. Cardholders that are unsatisfied with their primary physician simply make an appointment with another doctor, which means the new physician will have to order all basic tests again. "This is an unnecessary expense because the tests have already been analyzed by the previous doctor. Patients that continue changing primary doctors will increase health reform costs," Rodriguez said.

A similar situation occurs with the freedom of selecting specialists.

"If freedom in selecting drugstores, laboratories, dentists, and specialists is given and no capitation is set, general capitation should be increased to $300," Rodriguez said, adding that the government should set an adequate capitation. It would allow private hospitals to hire many employees laid off by the government’s sale of CDTs and hospitals, he said.

"One alternative is for ASES to be the health insurer. Then, it could contract insurance companies to handle the administrative processes. Right now, health insurance companies are passing the risks on to those providing services. It should be the other way around," Rodriguez said.

One common abusive practice consists of drugstores billing for full prescriptions when they have given patients only part of it and the cardholders never return for the balance of their prescriptions, Rodriguez said.

Another example of abuse is occurring often at hospitals. It is the case of indigent persons asking to be checked by emergency-room doctors. "They (indigent persons) know the acronym, EMTALA, of the federal law which states that people must be treated at emergency rooms regardless of whether they have money or a health card. Federal law also permits hospitals to foreclose homes to receive payment for services. Although this is happening more and more, the homeless have nothing to foreclose," Rodriguez said.

Rodriguez added that too many people in Puerto Rico have the misconception that health care is free and that, because the government pays for it, they are entitled to free health services.

Vazquez Deynes believes the government should be more strict in qualifying health-reform cardholders and agrees with Rodriguez’ suggestion that a clearinghouse be established.

There are too many cases of liars claiming to be unemployed to receive health cards, yet not only do they have medical plans at work, their spouses do to, Rodriguez said. He added that a clearinghouse, similar to banks, would detect this abuse immediately.

Rodriguez also favors that cardholders pay a portion of the cost. The health reform plan has deductibles of 50 cents to three dollars.

"More money should be spent by the government and the health insurance companies educating patients about the importance of taking care of their health," Vazquez Deynes said. He added Triple-S has educational programs but much more can be done in coordination with the government.

At the same time, Vazquez Deynes thinks education and communication among the health reform components—government, insurers, providers, and patients—are insufficient. "The government should promote forums in which representatives from different sectors discuss problems and bring solutions that do not increase costs," he said.

In general, health reform patients have increased hospital costs by 10% to 15% because they lack good health care. "Within two to three years, with proper care, health reform patients will be better off physically and costs will level out," Rodriguez said.

Meanwhile, many private-plan patients have gone to hospitals where they can avoid sharing rooms with health-reform patients or are demanding doctors have separate days for seeing health-reform patients.

"Many clients left us [HIMA] for San Juan hospitals because they could not tolerate a reform patient who screamed, used bad language, and was visited by 25 relatives a day," said Dr. Hector Ugarte, who is in charge of making Hima cost-effective. This has resulted in the conversion of all HIMA-hospital rooms into double rooms to accommodate health-reform patients.

This Caribbean Business article appears courtesy of Casiano Communications.
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