photo Araucania Regional Hospital by Pablo Trincado
An update to this article is here.
Part of daily life here in Santiago involves running around town doing in person what you might otherwise do over the internet or over the phone in countries less burdened with paperwork. Chilean have a word for this, haciendo tramites, and they set aside ample time for that. Employers expect to lose employee time as their employees are shuttling about the city visiting the notary or, more likely, the health insurance company.
A few years ago, I was working with a guy from Peru who spent much of his work week shuttling between the private insurance company—those are called Isapres—and various clinics (Clinic means hospital and not a small outpatient facility, but clinics here serve both functions.).
Francisco was spending at least 3 hours each week running around trying to get reimbursed for medical expenses spend on his wife and three kids. One of the girls had asthma. That was made worse by living in a damp room in a house owned by his mother in Independencia. It was damp because she insisted on watering the lawn in this parched country of few lawns.
Francisco was keen to get back every peso he spent, plus he was trying to get his name removed from DICOM for other medical debts he had not paid. DICOM is the dreaded credit reporting agency here, operated by Equifax. Equifax is an American credit reporting agency, except the situation in Chile for people blacklisted by Equifax is much worse than in the USA. In the USA, you can still get credit if you have a poor credit score. In Chile, you cannot: there is no score, you are either listed or not. The government has had to step in several times to force DICOM to purge people from their list. (It would seem the latinos are under the heel of the gringos now as before.)
Anyway, here is how Francisco spends three hours each week:
1) His daughter went to the clinic for asthma consultation with a doctor perhaps the previous week.
2) At that time, Francisco´s wife took her to to the private clinic and took a number, as is the custom here, in order to wait for the opportunity to approach the cashier to make payment in order to see the doctor. Then she returns to her seat and waits to be called. You can make this kind of appointment by phone or internet.
His wife puts her thumb in the fingerprint reader, to verify coverage, and the machine calculates the bono (what the insurance company pays) and copago (what the insured pays). For a 20,000 CLP consultation the copago is probably 9,000, more if you do not go to one of the clinics that is affiliated with the insurance plan.
3) Francisco has a 2nd insurance policy, one designed to cover his out-of-pocket expenses and pay for medicine. Lots of people in the professional classes get this extra insurance from their employers. None of the private (Isapres) or public (Fonasa) insurance plans in Chile pay for medicine. That is a large problem. Consequently, many poor Chileans cannot pay for their medicines. Even middle class people have trouble with that, as medicine costs just as much as in developed nations. The pharmacies here have been accused of collusion (price fixing) by the government. The American chain Walgreens recently bought one of the chains here. Perhaps that will help increase competition to drive down prices. Pharmacies here too have lobbied against and defeated a bill that would let other stores sell over-the-counter medicine, like aspirin. They need competition to shake up their business and drive down prices.
Anyway, Francisco carries his forms in person to the human resources person at his office. She acts as the liaison with Metropolitan Life Insurance, who offers this extra coverage. Their form has to be filled out exactly per the instructions or they will not pay. The doctor must sign it. The pharmacy must stamp it, and give him a copy of the prescription. Francisco mastered this system so well and it is so high in his thinking, that he carries these forms with him. If he were to go to the see the doctor without this form then he would have to return later and have the doctor sign it after-the fact. (I never did master this tedious process, so usually was rejected by the insurance company. Now I work for myself and do not have this extra insurance, so pay out of pocket for medicine.)
Francisco is among the 20% of Chileans who are in the private Isapres insurance system. The rest are with the public plan, Fonasa. Some have no insurance at all, like business owners who have not kept up insurance or pension payments or those who for whatever reason have not signed up.
Chileans pay 7% of their wages into a fund administered by the Isapres and Fonasa to cover the insurance premium. Only those making 600,000 CLP or more could afford to pay for Isapres since the premium is about 42,000 CLP, which is 7% of 600,000, for someone young and healthy. The premium rises sharply with age. Women pay more than men.
You could not call this 7% levy on your salary a tax, because the money in excess of the premium accumulates there. Francisco can use that excess to pay for glasses, the dentist, or anything not fully covered by his plan. Or he can wait until the end of the year when the Isapres reimburses him for these excess payments. His insurance premium is about 58,000 CLP for himself. I am not sure how much more he pays for his wife and children (cargos).
The Situation with Medical Care in Chile
The current Bachelet government is planning to address several problems with the current medical system.
First, are the sky-high profits of the Isapres, who say that comes from people not taking advantage of government plans to pay for certain medical expenses for free. It also helps that they can turn down coverage for people with preexisting conditions.
Second, is that 7% fee, called a tax, which is not a tax. Her government wants to make it a tax, that would not be returned to the taxpayer, so it can be used to pay for expenses for the entire populace and not just the 20% who have private insurance. (All people pay the 7% levy, even those in the Fonasa system. Only pensioners are free of this obligation.) That would help pay for another part of her agenda, which is to pay for medicine for those who cannot afford it for certain chronic conditions whose medications are dear.
Some medical care here is free. In Chile, 80 of the most common, most dire, chronic ailments are paid by the state, even for those with private insurance. This is called AUGE-GES,Garantías Explícitas en Salud AUGE-GES. That pays for treatment for hypertension, many forms of cancer, and 78 other maladies listed here. This reduces the cost down to only one copago; the state pays the rest. The paperwork burden and the need to hacer tramites is still the same, as the insurance companies administer the system. But waiting in line and shuttling between the hospital and insurance company is better than having to pay 5 million CLP for hospitalization or go bankrupt because of medical bills, like people do in the USA.
Most problems and their solutions in Chile seem focused on the capital. This leaves people in the provinces wanting. To fix that and reduce wait times, the government is rushing to build hospitals up and down the country, but there are not enough doctors to staff them. The reason for this is they all want to work in the private clinics in Santiago where they can make several times the 800,000 CLP monthly salary that a doctor in a public hospital earns. Also some specialties are capped as to the number of students who can study that each year. For example, there are only 12 positions in the entire country for ophthalmologists each year. Consequently the wait for those people using the public system who want to see an ophthalmologist can be many months. I can see one next week if I want to, because I have Isapres.
To increase the supply of doctors, the government is handing out visas for anyone who wants to work here. Doctors and coming from Spain and Colombia, but there are not enough.
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May 12, 2017
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