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Ángela Ávila, Executive Director of the Health Insurance Administration. (GFR Media)

According to health industry experts, even if it obtained the approval of the federal government, the new pillar of the Government Health Plan (PSG, Spanish acronym) is not ready to start operating.

Last week, Ángela Ávila, Executive Director of the Health Insurance Administration (ASES, Spanish acronym), acknowledged that the Centers for Medicare and Medicaid Services (CMS) had not approved the actuarial certifications of the new administration contracts for the reform.

Without the endorsement of the US government, the state government cannot use federal funds to finance PSG.

But last night the official closed the door to the possibility of having to postpone the implementation of Vital - the new Health Reform model - until the end of the year.

"Plan Vital (starts on) November 1," said Ávila in written statements.

"We have continued to receive contracts from supplier networks as they have been represented by insurers," the head of ASES added, although she did not specify if CMS already endorsed the actuarial certification of the new contracts.

Even if they had that authorization, the executive president of the Puerto Rico Hospital Association, Jaime Plá, said that there are still unfinished business that would delay the start of Vital.

“We are dealing with five different contracts and, if they are not ready, then fantastic, but it must be the last time" that the beginning of the new reform is postponed, said the leader of the Puerto Rico Hospital Association.

On Friday, Avila had assured El Nuevo Día that the implementation of the new reform could also be delayed if the government was not satisfied with the networks of suppliers contracted to date by the five entities that will administer the PSG. These companies are Triple-S, Plan de Salud Menonita, MMM, Molina Healthcare and First Medical.

Originally, October 1 had been set as the start date, and then it was postponed to November 1.

"There must be more transparency (in the process) because, if not, that creates instability and lack of credibility in the system," added Plá, who believes that the state government lacks the funds to finance the Health Reform, which is why It is difficult to visualize its continuity without the financial support of the US government.

An anticipated problem

Meanwhile, José Sánchez, from the Clinical Laboratories Association, said that the possibility of postponing the new reform was something that was anticipated several weeks ago.

"Insurers are forcing providers to sign contracts without fees, and the system cannot stand it anymore. There are problems with hiring providers, particularly specialists," he said.

He added that CMS is demanding that ASES show evidence of contracting supplier networks. "You have to start with the whole process again and have a single insurer because the money is not enough to (finance) the five (insurers selected to administer the new reform). A new model should be developed with the participation of suppliers," he said.

According to Sánchez, this situation jeopardizes the federal funds that support the reform, and reminded that these resources end in September, next year.

"In January, they have to go to Congress to ask for more funds (to be used after September 2019) and how will they ask for them in this situation?" he said.

Among the obstacles of this new model, some also point out that insurers allegedly urge suppliers to sign contracts without including the rates they will pay for the services provided.

"The system is not ready. There are still lots of hospitals and doctors that have not been hired. Insurers are pushing (to sign contracts without fees), and ASES knows it. It is not a bad idea (to postpone the starting date)," insisted Víctor Ramos, president of the College of Surgeons.

Avila also said on Friday that the local government has a reserve to ensure that services are provided during the month of November. In addition, she explained that the local government can recover reimbursements from the federal government retroactively up to two years.

At the beginning of February, the United States Congress approved a bill that allocated about $ 15 billion to mitigate the disaster caused by Hurricane María. That measure included an allocation of $ 4.8 billion to fully finance the local Medicaid program with federal funds. That is the allocation that will run out in September 2019. Several packages of federal funds have saved PSG from falling into the fiscal cliff since last year.

The possibility that suppliers fees were reduced has also led to complaints among members of the health industry. The Fiscal Plan had established that, when setting rates, insurers should use the 2016 Medicare rates as a guide.

This implied a decrease, so when faced with complaints from different suppliers, ASES requested the Oversight Board to use the 2018 Medicare rates as a reference, which are higher.

The petition was approved at the end of August, but there are those who talk about alleged pressures from insurers for suppliers to sign contracts with no rates or lower rates than the current ones, according to the 2016 guidelines.

"Patients have to follow their doctors and suppliers have to take over the process and don´t let insurers or the government go over them,” denounced Ramos.


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