January 21, 2022 5:33 pm

Copay or no copay? That is the question

The health problem in Argentina once again occupied spaces in the media with the announcement of the implementation of co-payments for social and prepaid works. This was only an emergent of the crisis that the system is going through.

We want to offer in these lines our perspective of the problem of manifest asymmetry between fees and values ​​perceived by doctors and providers.

Since 2005, the increase in available resources was 46 times for EMP (Prepaid Medicine Companies) and OSN (National Social Work), while the increase in costs for ophthalmological practices was 31 times although the increase in fees was only 12 times.

This difference represents a 153% gap between fees and costs in the 2005/2020 period.

The health system is on the brink of economic collapse and the situation of health providers has no alternative solutions. This is no longer reduced to a financial crisis.

But it is important to specify in numbers what is happening in our health system where in this terminal crisis the asymmetries are deepening and are part of the problem.

When we affirm that the system has a structural problem, we can demonstrate it in numbers, according to multicenter studies carried out by Cadime (Chamber of Medical Diagnostic Institutions), the Commission of Administrators of the CAO (Argentine Council of Ophthalmology) and Cameof (Chamber of Medicine Ophthalmological).

The resources of the OSN and EMP system, the evolution of costs and fees indicate that since 2005 the increase in available resources was almost 46 times in the prepaid medicine companies (EMP) and in the national social works (OSN). At the same time, the increase in the production costs of ophthalmological practices was 31 times, this far exceeds the increases in tariffs (almost 12 times) granted to independent providers, the gap between these indicators increasingly widening.

To this asymmetric scenario from where we see it, we must add some condiments such as inflation, the movement of the exchange rate and the parity of the sector.

Until 2020 the gap between the costs and the income of the providers amounted to 153%.

Considering the study carried out by the Ieral of the Mediterranean Foundation. The same in the first quarter of 2021 concluded:

“The sector has no respite. Despite the fact that the ATP allowed some relief in the harshest moments of the quarantine, its replacement in the first quarter of 2021 by Repro II, proposes less financing for clinics and their employees. This program, in turn, places privately managed health institutions up against a rock and a hard place: if they exceed 35% of the turnover for the same month of the previous year, they may lose this benefit. “

Integrating the report into our analysis, we can infer that during 2020 and 2021 the 153% gap increased again, as costs once again grew above the income of healthcare providers.

The Superintendency of Health Services (SSS) on July 30, 2021, in its resolution 2125/2021, authorized an increase in tranches of the fees that members pay to prepaid medicine (EMP) close to 41.5% in total . Let us remember that until that moment during all of 2020 the authorized increase reached 26%. Which makes a total of approximately 67.5% for the two periods. The accumulated inflation 2020 and 2021 (projected) reaches 100% and an almost 70% devaluation for the same period if we take the evolution of the official dollar. Let us remember that for example in ophthalmology 40% of the costs are expressed in dollars. At the same time, the health insurance companies increased by 36.1% in 2020 and by 45% in 2021.

The 153% gap until 2020 increased after 2020 and 2021 and the clear explanation is mathematical. The costs of the provider activity for the two periods increased by 80% considering the variations generated by inflation, the movement of the exchange rate and the parities as determining elements of the cost structure of ophthalmological providers. Revenues increased by 26% in 2020 and if resolution 2125 was met, by 2022 by 41.2%. The simple addition and subtraction shows us that we are worse than in 2020. As if to explain it to a 10-year-old child, 153% + 80% – 26% – 41.2% = 165.8%.

Medicine based on mathematical evidence, the remedy is worse than the disease and the gap is today 165.8%. That is the need of the provider sector to cover its costs and therefore little can be done with a controversial 9% that for many is like a drop of water in the desert. Health providers must restore their tariffs by 165% in order to be viable in an Argentina immersed in inflation and legal insecurity that will make this gap grow by not providing substantive solutions.

Another big problem is that the affiliates to the financing companies (social works, prepaid, mutual) who are treated in the health centers pay their fees every month to have coverage. These entities then pay the health institutions for the services provided to their members, but not immediately. In this way, during 2020 and 2021, the income of private providers was not only affected by the time elapsed between a service being provided and financed, but also by the lack of actual updating of the amounts. In this framework, the increases that are transferred partially and late are not only liquefied by the evolution of inflation, exchange rate and parity, but also due to the extension of the payment terms, the situation that theoretically compensates for these asymmetries ends up being more negative. than the initial situation. The two basic financial principles are violated. The value of money in time, which is key in Finance, in the sense that a peso today is always worth more than a peso tomorrow. And the principle that considers risk, summarized in “Better a bird in hand than a hundred flying” is a Spanish saying that comes from the Latin proverb «There is a bird on the right, better than four out»

The health system has its successes and its fallacies, many gray and black. If this asymmetry persists, the excellent medicine that Argentina knew how to achieve will only be a memory, a nostalgia for times gone by. The problem, as can be seen, is not reduced to copayments, but to correcting the figure and saving health spending from expensive administrative intermediations that give little added value to benefits. Why prepaid and social works do not have the means to pay this increase despite not having covered the cost of benefits and maintaining a gap is the subject of another debate that we owe ourselves, but something must change.

López Mato, ophthalmologist, member of the Cameof Board of Directors; Ibarguren, Master in Health Services Administration, Secretary Cameof


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