2024-02-14 06:50:42
With a universe of 10,468,341 people affiliated with the Family Insurance of Healththe vast majority of Dominicans (10,771,504 according to the last census) have, in theory, roof for your main demands medical services.
But reality is often complicated and insured end up disbursing large sums of money to obtain the attention they demand, increasing the profitability of a business, the healthwhich its main actors are distributed.
A mixture of factors reduces the efficiency of the system. According to Arismendi Diaz Santanaone of the creators of the model social Security of the country, the first of them is the bad managementwhich in his opinion, translates into a waste of money in payments for personnel who do not provide the service to which they are obliged and who profit in private practice.
“Health has been commercialized. First of all, for the medical sector. This commodification grows to the extent that the public response is increasingly less efficient and reliable for the population,” he maintains.
From the other sidewalk, although agreeing that the health has been left to the game of the market, the doctor and former president of the Dominican Medical College (CMD), Wilson Roa, attributes the ills of the sector to the low investment state and the intermediary companies between the State and the patients, that is, the risk insurers of health (ARS).
“What happens is that health is not a priority for governments and that’s why they took it to the market. How can we explain that intermediation decides today on scientific medical criteria? We have a law that protects business. A law that opens hospitals to private business,” insists Roa.
Since 2001, Dominicans have had the Dominican System from Social Security (SDSS) created by Law 87-01, although its entry into force was gradual starting in 2002.
In addition to regulating, the legislation aims to “develop the reciprocal rights and duties of the State and citizens with regard to financing for the protection of the population against the risks of old age, disability, unemployment, survival, illness, motherhood, childhood and occupational risks”.
The system is designed in three regimes: contributory (public and private workers), subsidized (with contributions from the State) and contributory-subsidized (only the first two work) and open to private sector participation.
For financing, a scheme is established collection which follows the following equation: the employer sector deducts the workers’ contribution from the payroll and passes it, along with its own, to the Treasury of the Social Security. The National Insurance Health (Senasa) and the ARS will present a monthly bill based on the amount of affiliates and at the cost of the basic plan health. Once the invoiced amount has been received, these entities must in turn pay the Service Providers. Health in a period of no more than 10 days.
The amounts of SDSS
From 2008 to October 2023, at SDSS has received more than one billion, five hundred and ninety thousand, eight hundred and fifty-four million pesos (1,590,854,449,300), for the concept of collection (including interest, surcharge and fines), contributions from the Central Government and investment returns, as published by the National Council of the Social Security (CNSS) in their monthly bulletins.
Of that amount, 90.5% (1,439,096.8 million) belongs to the collection of the contributory regime, 8.3% (131,613.1 million) are government contributions to cover the affiliates of the subsidized regime and 1.3% (20,144.4 million) of return on the investments of the SFS and contributions.
Until last October, and since the system began in November 2002, the expenses They were over one billion five hundred ninety-five thousand eight hundred sixty-four million pesos. “Funds paid to Family Insurance of Health (SFS) of the RC in the period between September 2007, the date on which said insurance began, to the month of October 2023 amounted to 633,106.1 million pesos, of which 92.7% was assigned for the care of the health“says the CNSS in its October 2023 bulletin.
It details that 2.0% was allocated to cover the National Fund for Medical Care for Traffic Accidents (Fonamat); 3.8% was assigned to the Subsidy Account (common illness, maternity and breastfeeding) and 1.1% was paid as a commission to the Superintendence of Health and Occupational Risks (Sisalril).
“The total amount paid to the ARS (29 between public and private) from 2007 to October 2023 reaches the sum of 657,158,033,084.92 pesos, to cover the Health Services Plan Health (PDSS) and the Medical Care Fund for Traffic Accidents (Fonamat)”.
In the month of October alone, the disbursement to the ARS was 73,377.3 million pesos.
The amount that the service providers of healthincluding doctors, clinics and laboratories, is not known in detail, but the disagreement of doctors has led them to protest against the ARS and the stewardship of the system.
The union that groups them has even suspended the service to several ARS demanding, among other things, the unification of the fee rate and that it be indexed according to accumulated inflation. They also advocate an update of the catalog of benefits so that there is a greater roof to the affiliates.
The constant complaints
Last year, this medium published the testimony of a woman, lower middle class, who spent 12,000 pesos a month on medications to treat her liver cirrhosis, because her insurance does not cover any of the drugs she needs.
Rafaelina Veras’ insurance did not cover the Pap smear because her gynecologist did it on a liquid basis and that modality, which is presumed to be more effective than the conventional one, was not in the catalog of roof from his insurer, he told Free Diary.
The General Directorate of Information and Defense of Affiliates (DIDA) registered, in the month of November alone, 3,183 complaints and complaints of the affiliatesof which 1,573 are related to disability, old age and survival insurance, and 555 to family life insurance. health. In that month, the DIDA had to issue 354 letters of no roof to the affiliates.
What the system offers
He Basic Plan of the SFS has a list of more than 11,400 medical services and procedures ranging from prenatal care to terminal illnesses to cover the life cycle of affiliates. All with level of roof from 70% to 100%, in some cases unlimited, others with consumption limits. For example, a cornea transplant is covered at 80%, as long as the process does not exceed one million pesos.
The basic plan also offers a list of 560 different medications that the affiliated population can access with a minimum payment, although subject to an annual limit of 12,000 pesos, in accordance with the increase of 4,000 pesos approved by Sisalril last November, which implied a per capita increase in the contributory regime of 128.08, going from 1,555.14 pesos to 1,683.22 pesos.
The catalog of centers health and available doctors depends on each insurer.
He division of discord
Roa (left) and Arismendi Díaz Santana. (FREE DIARY)
He Medical College Dominican Republic and the owners of private clinics persistently demand the revision of Law 87-01 so that the resources managed by the system more equitably benefit service providers and patients. affiliates. They understand that the majority of the profits remain in the hands of the ARS.
For Dr. Wilson Roa, the way in which resources are distributed is a scam against patients and against doctors.
“What the insurance covers for me (doctors per consultation) is 500 pesos, less the 10% withholding that the ARS makes when it pays me, less the 18% that the DGI retains, that is, 28%. “They give me 340 pesos, in 65 or 90 days.”
In addition to considering that the amount is small, the doctor complains that the ARS are the ones making this payment, when the State should do it.
In Díaz Santana’s vision of the commodification from health, doctors have a main role. “Right now, the Medical Association is dominated by people who thrive and do good business in the private sector. Consequently, their approaches are aimed at maintaining a status quo that disfavors public medicine and privileges private medicine, because with that they get benefits.”
Díaz Santana gives as an example the co-payment that patients must make at the time of the consultation, which is usually between 2,000 and 3,000 pesos and is paid in cash to avoid paying taxes, he says.
“The basis of all this is to feed the inefficiency of the State in the public health sector, because the more inefficient the hospitals are, the less confidence the population has that they will receive a service… the more privatization grows”Arismendi Diaz SantanaSocial Security Specialist
Díaz Santana thinks that, contrary to public discourse, doctors do not want rates and fees to be regulated, because if it is limited through the catalog they would not be able to establish whimsical differences and would have to pay the treasury for the entire amount charged.
He also says that a large number of doctors manage to have very good salaries in the public sector and do not work, making the burden of those who do carry out their work heavier. They are the same ones who do big business in the private sector “and that clashes with the objectives of the social Securitywhich are putting the affiliate in the foreground”.
He believes that Law 87-01 has shown that the system is not oriented to satisfy the needs of the population, but that the Public Health budget It is destined to feed a class that it defines as parasitic, because it does not work or have responsibility for the health public.
That is why he considers that the fundamental thing is the system management. “Here you can multiply by ten the Public Health budget and if the way resources are allocated and hospitals are managed does not change, those resources will not reach the population.”
He is a journalist at Diario Libre.
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