The Superintendence of Health Services diluted the Single Reimbursement System (SUR) a few days ago and in its place created SURGE, the Single Reimbursement System for Disease Management.
Both correspond to a support program for social works, so that they recover part of what is spent on care for patients with diseases considered "high cost."
Below, the aspects for and against this change.
The announcement came out in the Official Gazette through resolution 731, on March 28.
Roughly speaking, the Superintendency seeks to modernize a reimbursement circuit that has existed since 2012, but which has become outdated, since all documentation had to be submitted in "paper" format.
Although it is not yet operational, SURGE will implement a
digital management platform
that is supposed to make processes more expeditious.
It will also imply a
paradigm shift
: reimbursements will focus on the diseases themselves, and not on a list of drugs to treat them, whose updating, as it is easy to imagine, had the problem of always lagging behind the rapid progress of therapeutics.
Apart from these items, the SURGE came with a surprise.
Nothing less than a
cut of 47 diseases
,
of the 130
that were contemplated for reimbursement within the framework of the SUR.
The background of the changes is access to medicines.
Photo: Mario Quinteros
Health, social works and reimbursements
It is notable that in order to report a change in a health program in a journalistic way, all the sources (four) agree to ask to speak
off the record
.
From the official sphere they discussed the idea of a "cut"
.
For several reasons.
The first is that, they said, high-cost medicines and treatments represent a dynamic scenario that, in the eyes of the authorities, had to be redefined.
It was done prioritizing the
most prevalent pathologies
.
The second reason (in line with the above) is that the diseases removed from SUR (now SURGE) had a very low utilization rate, so they did not represent the largest budget of the program.
They reported that, based on a recent analysis, the pathologies contemplated in the SURGE represent 97% of the amount reflected in the files initiated by the obras sociales in their reimbursement requests.
These points come together in a statement that, they point out, should provide peace of mind, and that is that
the changes implemented should not have an impact on patients
.
What is at stake is whether the change in refunds may affect coverage for certain diseases.
Photo: Shutterstock.
The highlights of health coverage
It must be clarified that requests for reimbursement to the Super can only be initiated once the medication or treatment in question has actually been paid for by the social work.
Although this protects the patient from suffering the times of the institutional bureaucracy, it is not unreasonable to wonder if the reduction in the number of SURGE diseases could generate some harm (direct or indirect) to the patients of the almost 50 pathologies that were left out of the program.
Even though they are only 3% in pesos, an exhaustive parallel analysis would be warranted to investigate
the number of orders registered in relation to these pathologies
.
Or if several of them are no longer considered "high cost".
But, although the context does not help (complaints and litigation for non-compliance by health entities are commonplace in the news), the sources consulted, in general, agreed that the chances of an outbreak of conflicts are low. .
One of them, however, hesitated more than the rest.
The rules of social works
It must be clarified that if the high-cost treatment has authorization from the ANMAT and the Ministry of Health, and a doctor justifies the need to resort to this therapeutic route, the social work should pay for it, whether or not the Super will be
reimbursed
. .
However, one of the voices of the sector qualified the matter by stating that, "if the decrease in diseases with reimbursement means that the same amounts that the system has available are going to be distributed in a smaller number of pathologies, it is likely
that the coverage improves
in those that are in the program, but also, that
the reimbursement
of those that are not deteriorates”.
As an example of the almost 50 that "
are not there
" it is worth mentioning a few: ovarian cancer, hepatitis B, gastrointestinal cancer, hairy cell leukemia, chronic lymphatic leukemia, mantle cell lymphoma and follicular non-Hodgkin lymphoma.
Although the official version is that the list could be modified if necessary, the previous source was clear: "Every time the health system is underfunded, there is an
impact on coverage
."
Health financing: a delicate balance
Those consulted agreed to highlight an aspect that speaks volumes about the
health
conditions of the Argentine social security.
They said that the change from SUR to SURGE, even with its reduction in diseases, should not generate a negative effect on people because
the system, anyway, was already broken
and reimbursements were being received with a long delay and an update due to inflation. almost nil.
"Last year,
the update was 50%
," protested one of the sources in the sector.
"For almost 20 years, the social works paid for the treatments and
over time they recovered them
, but poorly, deflated. Until 2020 there were cases filed in the Super for more than 10 years," he said, although he admitted that "it is true that It is very difficult to cancel the number of orders that come from 300 social projects with 20 million beneficiaries."
Bankruptcy is not denied
in the official sphere
.
A "prioritization" was made (there is a "budgetary logic behind it", they outlined).
And, like the other sources consulted, the idea was outlined that the SURGE (more limited quantitatively but focused on the most important high-cost diseases),
endows the system with "realism".
FSR, SUR and SURGE
What are the SUR and its parent company, the Redistribution Solidarity Fund or FSR, technically?
It is worth knowing this circuit to at least try to understand the different positions.
Each month, the AFIP takes the money that comes from the contributions of the population with formal employment and divides it in two.
Slightly more than 80% of the proceeds go to social works (to cover medical and social benefits) and about 17% goes to the so-called
Redistribution Solidarity Fund
(FSR).
The budget that this fund manages is around
20,000 million pesos
, which are allocated, in turn, to various “subfunds”.
They are, one might say, the financial patches on a broken system.
"Bank", they protest from the social works, because while scientific innovation advances rapidly, with magnificent but expensive
therapeutic innovations
, the percentage of contributions that reach the entities was defined 50 years ago, based on an average salary and a cost of life (from the 70s), which no longer exist.
SUR (now SURGE) is one of the programs included in the FSR.
It takes 30% of that budget of 20,000 million, so that it has about
6,000 million pesos
.
Technical changes from SUR to SURGE
According to a fourth source closely linked to health, who completed important institutional tasks a few years ago, SURGE promises to bring "
more transparency
".
He said it in allusion to occasional "stir ups."
“Before, a social work would buy a high-cost medicine for a cancer patient, for example, and with the prescription and not much else, perhaps they would already receive reimbursement.
Today he will have to present a set of documentation that
justifies the benefit
and makes it more transparent, ”he explained.
From the official sphere, this “murky” image is discussed.
They explain that there are 10,000
requests for reimbursement that arrive in the SOUTH per month
.
That there are 100 people working on them.
Half of these employees perform the benefit analysis of what the social work requests.
The other half audits the accounting part.
There are no automated processes.
Except for HIV patients, all the survey is manual.
high cost diseases
If all this matter deserves so many lines, it is because
high-cost treatments
have gained ground in recent years.
It is such a big problem that high-cost drugs are called "catastrophic drugs" since they carry such a burden that they could wipe out a family's economy.
From a medical entity they explained to this medium that “15 years ago, 'catastrophic' events represented 10% of the expenditure of social works and
now they are 30%
.
But if it is considered that the contribution pie has shrunk, it reaches 40%”.
The Redistribution Solidarity Fund has been in deficit for at least two years, they affirm in the official sphere.
The lack of sustainability of the health system is accepted by all.
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