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Wednesday, October 4, 2023

Does GESS belong to patients or beneficiaries?

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The abuses and the viability of GESS have been high on the agenda lately, with the Health Insurance Organization and the Ministry of Health looking for solutions. After the report of the Audit Office, the fears of the defenders of the system began to be verified, at a time when his timeless opponents again found the opportunity to undermine it. Many talk about abuse and over-indebtedness of the system by the providers, while others throw it at the beneficiaries. And because “outside the dance” we all have an opinion, “P” talked to two doctors, a staff and a specialist, who capture through their descriptions the true picture of GESS and comment on what needs to change to improve the system. Characteristic of the problems faced by doctors is the fact that the specialist doctor, who deals with children, asked to remain anonymous, stating that every time he spoke openly he had problems with his work.

They blackmail the PI

Both doctors consider that one of the main problems of GESS is that the OAU left the beneficiary to do whatever he wants. As the personal doctor Costas Schizas told “P”, the result is that healthy beneficiaries try to make the system sick every day. Doctors, as well as beneficiaries, do not know how the system works, with the specialist doctor noting that only when the constant “blackmail” that personal doctors receive on a daily basis stops will the system improve. According to him, the beneficiaries have not realized that they are paying a contribution to the GESS, so that they can be provided with the necessary health services when needed, with the result that with a small leap they ask for a referral. The doctor even referred to the frequent phenomenon of beneficiaries approaching him for no reason and cause, while in their file at GESS it seems that one or two doctors of the same specialty had previously visited, with the diagnosis being the same. The reason is very simple: Because the referral they have in their hands allows them two or even three appointments, they take full advantage of it. Thus, instead of a visit to the personal doctor being all over, with the referral system the system will reimburse at least 1-2 visits to a specialist doctor, who in turn may take advantage of it in order to have additional profit. As Dr. Schizas also confirmed, many times beneficiaries make appointments on their own in various specialties and either remember to ask their personal doctor for a referral at the last minute, or in several cases they ask the secondary health professional to ask for a referral for them. Dr. Schizas even found that while the philosophy of GESS says that everyone should go through the office of their personal doctor, so that the beneficiaries are filtered and the resources of the system are not wasted, in practice the personal doctor is decorative. >

The weaknesses

The fact that the beneficiaries do not know what GESS is, how it should work and what their obligations are, is also shown by the fact that there are people who ask for a referral to go to a gynecologist or dentist. In fact, according to Dr. Schizas, because the dentists can not prescribe through GESS, they give the prescription to the beneficiary, who goes to his personal doctor to prescribe the medicines through the system. And this, as he explains, happens with other specialties, but even with secondary or health professionals who are contracted with GESS. If the beneficiary has a specialist doctor whom he visited before the GESS, it is common, according to Dr. Schizas, to go to his doctor and then go to a professional within the system for his medicines. In fact, there are cases of health beneficiaries in the age of 20-30 years who remembered that they need to do general tests or fatigue tests every year, for no reason, just because they deserve it and because they believe that GESS belongs to them. The only way for GESS to succeed is for all of us, providers and beneficiaries, to realize that we are its employees, said the specialist doctor, who in fact pointed out that there are many colleagues who exploit the wishes of the beneficiaries and their weaknesses. system.

Control gaps

One of the main weaknesses of the system that doctors identify concerns the controls. For two years, more than 25 million referrals have been issued, while in a system with only 920 thousand beneficiaries, 186,555 surgeries were performed, in addition to the eight million visits to personal doctors and about one million visits to specialist doctors. The question that arises is whether all this needed to be done and what the real needs of the population are, with doctors emphasizing that there is data that the ODA can turn to, either from Cyprus or from other countries, to assess the data. Even control over how data is entered into the system is problematic, as a doctor who has seen a patient for 20 minutes can easily say that the examination lasted 40 minutes and increase his or her earnings. There are doctors who can put you in the operating room in the slightest, without even bothering to find out your history, said the specialist doctor, who stated that there are many doctors who follow this practice in the clinic in which works. He even stated that when he reported the problem to OAU officials, the answer he received was that he should make a written complaint, with the organization asking doctors to report their colleagues. As “P” is informed, for one of the cases of the six specialist doctors, who according to the report of the Audit Office received more than 600 thousand euros for outpatients, there is a complaint from a beneficiary that the system was charged with services it did not receive. After the beneficiary submitted a written complaint that the provider in question charged the system for services it did not provide, it received a response after almost two months, according to which there is insufficient data, with the OAU compensating the doctor. A competent source even told “P” that such a thing happens many times, as it is not possible to be behind every medical operation to make the necessary check-up. In addition, there are complaints about doctors who, while being reimbursed through the private insurance that the beneficiary has, charge for the services they offer to GESS, with the result that they are paid in double. Again, OAY has received relevant complaints, which it is unable to investigate.

It is paid by the “good”

The problem with the abuses is not that the GESS is called to pay more, since due to the global budgets such a thing does not exist. But what is happening, according to the doctors, is that the “good”, that is, those who do not abuse the system, are called to pay for the broken things of the rest. When the budget of a specialty is stable, this means that as medical operations increase, the price of the unit falls, and consequently the quality of the services provided. As the specialist explained, there is today a specialty where the price of the visit from 50 euros (6 euros from the beneficiary and 44 euros from the organization) fell to 18 euros. This means that in order for doctors to make the 50 euros of a visit, they have to see three patients, with the time available and the quality of the services they provide diminishing. In addition, by performing operations without reason and cause and with the doctor not knowing the history of the beneficiary, the issue of patient safety is raised. Answering the question what is the solution to make GESSY viable, both doctors suggested that restrictions be placed on the uncontrolled movement of beneficiaries from one doctor to another, but also to increase the controls.

Source: politis.com.cy

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