Here in Chile the medical insurance system is designed with two goals in mind: (1) provide coverage to everyone and (2) protect patients against major financial loss due to catastrophic illness. This article explains the Chilean insurance system taking information from the insurance plan web sites, talking to customer service people, and by interviewing Dr. Ana Luisa Advis Manzi, a pschychiatrist practicing in Santiago. Where applicable this article points out differences with the system in the USA where the costs, coverage, and problems in that system are a major issue in the presidential election there this year.
In Chile there are basically two insurance systems: the private plan, called “isapres”, and the public plan called, “fonasa”. Everyone is required to purchase insurance. A 7% tax is levied on the wages of salaried employees. These funds are put into an account from which the employee, in the case of isapres, can select insurance plans from a handful of private companies. Fonasa is basically just one company. Independent contractors such as medical professionals and attorneys pay no such tax so they purchase fonasa or isapres insurance using their own funds. There is no sanction for those who refuse to buy insurance. Instead what motivates people to buy insurance is the threat that they might have to pay cash for medical treatment. (That is a real threat here in Chile where unpaid debts are recorded in a system called “Dicom” run by the American company credit rating agency Equifax. If you have debts listed in Dicom you will have problem renting an apartment and contracting other services.) People cannot game the insurance system by waiting until they are ill to purchase insurance for there is a waiting period for coverage to kick in. Independent workers or people without jobs must wait 6 months for coverage while employees receive coverage straight away. Retired people recently had the requirement to pay 7% of their pension into the insurance system waived. Kids can stay on their parents plan beyond 18 years of age if they are students.
The vast majority of people here in Chile, roughly 80%, elect the public fonasa plan because their wages are not enough to cover a private isapres plan. Plus looking at the details there is really not much difference between the two options unless one absolutely insists on access to the more exclusive private clinics. Either way you will pay 7% of your income as tax so if you can afford isapres you would most likely elect that. At the high end of the income scale, say the top 20% of wage earners, employee wages are enough to cover the isapres premiums. Lower paid employees cannot afford isapres. In addition to isapres coverage, companies can offer complimentary health insurance to cover items for which isapres does not pay like copayments and, more importantly, medication.
Isapres premiums range from about $100 per month for an individual to $200 per month for a family or more. Prices vary depending on the age and sex of the patients. There are differing plans with differing levels of coverage and different treatment options with different premiums. An isapres plan usually contracts with specific private clinics for hospital stays so your insurance policy lists that hospital name so you chose plans based in part based upon what hospital you want. People applying for coverage the first time can be asked to undergo medical screening to discover any preexisting conditions. The insurance contract will be written to exclude coverage for these preexisting conditions. If the patient’s 7% salary contribution is greater than the cost of the coverage then these excess funds can be used to pay for medical treatment for which isapres does cover such as purchasing glasses or even copayments. As an example, a person working as a civil engineer in the mining industry might earn $4,000 per month at the high end of the pay scale. So their 7% tax would be $280 which is more than adequate to pay for isapres insurance.
Most of the people in Chile do not earn enough salary to afford the isapres insurance system. So they join the public fonasa insurance plan. There are four different fonasa plans: A,B,C,D. A is for the poor and it is free. Plan B is for those who make less than the minimum wage in Chile which is $360 USD per monthly currently put proposed to rise to $400 in pending legislation. Plans C and D require a 10% and 20% copayment respectively. Premiums are 7% of your salary. So if you earn, say, $800 per month work working as a bank teller your insurance premium would be $56. If you are in Fonasa plan for the poorest people you can go to the hospital or medical office and they will give you medicine free. But higher salaried Fonasa customers have to pay cash for medicine and Fonasa does not reimburse that. Needless to say the cost of medicine can be a burden for families.
Chile has taken the decision that the state should pick up the tab for any catastrophic medical issues. This GES/AUGE system is available to patients with either fonasa or isapres coverage. It is based upon the principle that health care in Chile is a right and not a privilege. This system of catastrophic coverage keeps Chilean people from being forced into bankruptcy due to medical bills as happens in the USA.
The GES/AUGE system maintains a list of catastrophic medical problems. GES means “health care guarantee”. It stipulates the proscribed treatments including the minimum number of days in the hospital, the proscribed medical procedures, medications, and maximum out-of-pocket expenses. Since there is a list of proscribed procedures that implies there are treatments for which GES/AUGE will not pay. This of course keeps costs from spiraling out of control as they have in the USA where Medicare costs are threatening the solvency of the health care system there and there is a debate whether there should be any cost controls at all. Isapres patients can opt out of this GES/AUGE system and use the isapres insurance coverage if they are not comfortable with the prescribed treatments plans given in the GES/AUGE system.
There has been criticism of the GES/AUGE system for its long wait times for treatment. Changes in the law have mandated a maximum wait time and wait times have been reduced significantly. The government is tracking this improvement in the law by showing the actual number of patients in the queue at the top of the GES/AUGE web page here.
In Chile there are two types of hospital systems: public and private. Hospitals tend to specialize in types of treatment they offer: for example one hospital might specialize in cancer and another in geriatric care. Certain private hospitals do not accept patients with fonasa insurance. Public hospitals accept both fonasa and isapres customers. Isapres customers are generally given better accommodation with areas of the hospital being separated for them. These private rooms are separated from the shared rooms as they are in US hospitals. Chile is very much a culture where class is important so people might elect a private room so they do not have to share it with someone from the lower classes.
There are three ways one pays to see a doctor. Either you can go to the insurance company and pay your copayment then they will give you a ticket which you give to the doctor which the doctor uses for reimbursement from the insurance company. Or you can go to the doctor and they will read your thumbprint and match that up against your insurance company who will calculate your copayment on the spot. You can also pay cash and go to the insurance company for reimbursement. Isapres and Fonsas patients generally have access to the same doctors. New changes in the law have reinforced the idea that fonasa patients should be able to see whatever doctor they wish.
Medication in Chile is priced about the same as medicine around the world or maybe slightly lower but still expensive. Recently government policies have been changed to require pharmacies to carry generic medicines when they are available as pharmacies have been accused of pushing the higher private name brand drugs. Here is a list of some common brand name medicines (non generic) and their prices. The first name shown is the name used in Chile. The second name is the chemical name or the name used in the USA. Finally the illness for which the medicine is used is given along with its price in US dollars.
Meganox, bipolar disorder and anxiet,Lamotrigina, $66
Concerta, ADHD and hyperactivity, Ritalin, $26
Neuryl, anxiety, clonazepam, $40
Ipran,escitalopram, depression $52
Atorvastatina, statins such as Lipitor, high cholesterol, $40
Valapex, diuretic type blood pressure medicine,high blood pressure $8
Once a patient has a prescription for a long term issue like asthma, high blood pressure, or other they can go back to the pharmacy as many times as they want to refill the medication. No prescription is needed. So there is no need to go back to the doctor or call the doctor over and over as is the procedure in the USA. The pharmacist simple sells the medicine in a box and the customer pays cash. There is no individually printed label, no counting of individual pills, and no involvement of the insurance company at the pharmacy as their is in the USA. For controlled substances like, for Ritilin, the patient will have a prescription valid for maybe two or three months. Then the prescription must be renewed by the doctor.
One unique aspect of the Chilean system is the insurance companies reimburse the employee for days out-of-work due to medical illness. This is called a “licencia”. One obvious advantage of this vis-a-vis the system in the USA is the employee does not have to worry that the employer will think the employee is not really sick because the doctor signs the licencia. When one is given a licencia there is no need to worry about employer sanctions and the employer saves the cost of the employee’s wages.
Chile does not have electronic medical records. Asked why not Dr. Advis suggested privacy issues and expressed concern that such information could be used by employers to discriminate against employees.
Recent outbreaks of flu and other respiratory illnesses–made worse by the air pollution in Santiago present in the winter–have caused the public system to be overrun with patients. In the last few weeks the situation was so dire that the military set up tents outside the hospitals to help care for the surplus of patients.