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  • Writer's pictureThe San Juan Daily Star

Physicians: Insurance companies act with impunity

Dr. Carlos Díaz Vélez, president of the Physicians & Surgeons Association of Puerto Rico

By Alejandra M. Jover Tovar

Special to The STAR

Dr. Carlos Díaz Vélez, president of the Physicians & Surgeons Association of Puerto Rico, on Thursday once again raised a flag against insurance companies that, he charged, are getting richer without offering the people the services they need or paying doctors fairly.

“We have been emphasizing for months that there is a health crisis in Puerto Rico, and we have been proposing alternatives for some time,” the physician said. “Today there is a situation that we have to present and educate the country with regard to the insurance companies. … We say that they do whatever they want, and that is the reality, where the life of each one of us is important, and we cannot continue to allow this group of insurance companies to continue seeking profit and not be for the life of the patients.”

Díaz Vélez criticized the fact that on Sept. 1, MMM Multi Health, First Medical, Mennonite Health Plan and Triple S were given the administration of the Vital Health Plan (known locally as la Reforma) “despite the systematic noncompliance of the companies which, for their convenience, did not hire the corresponding independent evaluations.”

“That is why there is no independent record of their dismal performance,” the doctor said at a press conference, where he was accompanied by other physicians.

According to a recent Center for Investigative Journalism report, “The ASES [the Spanish acronym for the Health Insurance Administration of Puerto Rico] targeted the Department of Health for the lack of reports corresponding to the audits for the period from 2018 to 2022.”

“We physicians know and denounce how we are treated in the 40% covered by Vital and 60% of the commercial health plan insurance,” Díaz Vélez said. “As for this part of private insurance, most of the insurers also did not submit in 2021 to the evaluation of the National Committee for Quality Assurance (NCQA).”

He added that “most health plans in Puerto Rico keep information about the quality and quantity of the treatments they approve for patients on the island secret, at a time when the shortage of doctors and restrictions on coverage of services and medications are aggravating the quality of health services in Puerto Rico.”

“The few plans that are open to evaluation and allow data to be made public received poor ratings for the services they offer to citizens, especially in the areas of disease prevention and treatment of mental health conditions,” he added.

“Physicians are required to submit a number of documents every year; we are required to have a good standing to characterize the quality of physicians,” Díaz Vélez said. “We are always under the public eye. All of us who provide service are under constant pressure to document what we do. What we do is required in the medical record.”

“Everyone here is required to be transparent, to provide details … but not the insurers,” he continued. “They are not required to meet quality standards. [Why all] the fear and trepidation when they promote themselves so much? Don’t they have the time or the courage to present to the country the quality parameters they use to improve themselves so that the patient has the knowledge to know that the plan complies with the measures? You will not have the contract just because you are an insurer. The government is there to supervise.”

The spokesman for the island’s physicians and surgeons asked that no medical plan be contracted if it does not have up-to-date certification from an independent entity of its quality metrics for private services. If it does not, its license must be suspended for three to five years, Díaz Vélez said.

“The Physicians & Surgeons Association of Puerto Rico is preparing an educational and informative initiative where, through a survey of physicians and patients, it will evaluate and give a rating to various quality criteria of each medical plan,” he said.

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