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The low amount of coverage continues to be the Achilles’ heel of Family Health Insurance

SD. It was 2011 when Mathilde (a false name) was diagnosed with grade 3, positive to estrogen, breast cancer in her left breast.

The accountant, today 53 years old, was amazed. It had been six months since her last mammogram which was fine, and in the following one she had to deal with the catastrophic disease, the low coverage of her medical insurance, and unemployment.

“I had to find RD$300,000 urgently in order to have a mastectomy. One of my children had insurance for parents, but it didn’t cover one cent either of the surgery, or for the previous exams. A part of the money was given to me and the other was obtained with complications that I still have,” the woman related between sobs.

Later, Mathilde went on to have a Basic Plan with one of the Health Risk Administrators with the largest number of affiliates in the country, in order to obtain coverage for her chemotherapy.

“I got this plan through my brother-in-law, nevertheless, my chemotherapy cost less than RD$3000 each month, I paid RD$1500, and the other part was covered by the insurance, which is to say less than half, and it is chemotherapy based on cortisone, which harms you. Right now my liver is close to having cirrhosis,” related the woman who for 19 years worked as the VIP collection manager of a financial institution. During that time she had a Premium insurance, which she never used.

Inattention to articles 118, 119 and 129 of Law 87 – 01 which creates the Dominican System of Social Security, the Family Health Insurance (SFS), should protect the health of the affiliate and their dependents; reach a universal coverage without exclusion, cover complex treatments for diseases and provide surgical assistance through its Basic Plan, but it doesn’t happen exactly that way.

At the present time, the amount of 1 million pesos per affiliate per year for a high cost diseases is established, with a coverage of 80% charged to your ARS, with the affiliate having to pay the difference of 20%, which should not exceed the sum of two national minimum salaries.

Nevertheless, for those who are newly affiliated, this coverage reaches them gradually, starting with RD$150,000, and completing the million when they have been contributing for nearly 2 years. The people’s complaint is that this coverage is low; it is granted for specific procedures, and not for what the patient needs, which in the case of someone affected by cancer, can reach an expenditure of an average of 2 million pesos a year in treatments.

“They give you 1 million pesos for what they want, because if they’re going to give it, they should give it for the procedures that you really need,” stressed the lady, who in spite of her difficulties, remains confident that she will overcome her disease.

Cancer constitutes one of the principal causes of death in the national territory, together with ischemic heart disease and cardiovascular disease. The latter, in spite of being the second cause of death in the country, does not appear on the list of catastrophic illnesses which are covered by the Health Service Plan (PDSS), neither are the oncological surgeries, which probably explains that non-coverage which Mathilde a complains of. She forms part of the population of around 2614 persons who are affected by cancer and who are attended at the “Doctor Heriberto Peiter Oncological Institute.”

“They have to be more humane, nobody wants to have cancer, nobody! And when it comes, what one wants is to have access to coverage for the medical procedures,” she added, trying to control her tears over the impotence which he feels, in addition to the lack of protection which she says she receives from the government sectors that are involved.

Other procedures for catastrophic illnesses or of high cost, such as lupus, rheumatoid arthritis, multiple sclerosis, hepatitis C, psychiatric issues and others, also do not have coverage in the PDSS.

“The magnetic residence for example is covered, but when they’re going to do it to a patient with rheumatoid arthritis, the ARS denies coverage under the allegation that it is rheumatoid arthritis, and this is outside of the law. A single medication can be covered for one type of illness, but not for another, and this is the situation that we have,” complained Gustavo Güilamo, an advisor on health risks.

The low coverage on surgical procedures produced 2129 complaints last year at the Directorate of Information and Defense of the affiliates (DIDA). So far this year they have registered 432 complaints, maintaining this low coverage as the second cause of complaints of the affiliates through the years.

Also this year, the seven ARS which form part of the Dominican Association of Health Risk Administrators (ADARS), and that attend 71% of the affiliates of the 23 ARS of the System and 92% of the affiliates of the 14 private ARS, provided 39.5 million services, and of this number,.535,410 were only for a high cost illnesses.

“The insurance ignores you; it makes you spend half a morning in order to tell you no, they do not approve you. While in the public institutions all they have is a bunch of coots who just repeat what you already know; you’re going to leave with your head hanging, with your letter from the DIDA, that is good for nothing,” said Mathilde with a faltering voice.

In 2014, the Family Health Insurance managed to collect RD$33,030,275,594.69, while the ARS ended with an income of RD$52,592,443,178.19. The people’s complaint is that the level of the collections is not reflected in the quality of the service that the affiliates receive.

“In the lack of coverage we have the Achilles’ heel of Social Security by the Family Health Insurance,” admits Nelsida Marmolejos, the head of DIDA.

This cannot continue to happen !

From the Superintendency of Health and Labor Risks (Sisalril), they are looking to have the Basic Plan guarantee the attention to the priority problems of social importance.

“In some countries they have opted for reinsurance in order to guarantee the attention to persons who have health problems that imply expenditures of a catastrophic character, as one of the options, but it is not the only one. What cannot happen, what cannot continue occurring is that because someone has expenditures of a catastrophic character, we tell them that we cannot attend them,” manifested the superintendent Pedro Castellanos, as he stressed that if they do not guarantee at least the health, the Social Security system has no reason to exist. “And until now, in this country, we have not achieved this.”

A plan that responds to the social demand

This year, the Ministry of Public Health is working with the National Council of Social Security (CNSS) and the Superintendency of Health and Labor Risks (Sisalril), in the revision and construction of a new Basic Health Plan, which, according to the health authorities might be presented in three months.

“The PDSS (the Health Services Plan) will be contrasted against this Basic Plan, and there we are going to see what we have, and what we do not have, which is to say how big a gap separates us from what would be the ideal to providing responses to all the problems of health in the country,” said Nelson Rodriguez, the manager of the issue at the Ministry of Public Health.

In the revision he assured this reporter that they would take into account the prevalence of diseases that demand greater attention, those that contribute more in terms of mortality, as well as those considered to be of high cost of catastrophic, such as multiple sclerosis.

Source: DiarioLibre

June 3, 2015

Category: DR News |

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Last updated March 28, 2017 at 5:30 PM
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