文章基本信息

标题：Mexican system a mix of public and private providers
作者：Edward M. Mendoza
期刊名称：Physician Leadership Journal
印刷版ISSN：2374-4030
出版年度：1994
卷号：June 1994
出版社：American College of Physician Executives

Mexican system a mix of public and private providers

Edward M. Mendoza

Access

Authority

Health care is a right according to Article 4 of the Mexican Constitution. Article 123 mandates that health services be part of the public social security system.

Population Covered

By law, there should be universal health coverage, but there are approximately 5-7 million Mexicans who lack access to health care. There are no health services in 30 percent of Mexican communities with a population of 500-2,500 people. In 1979, a program to deliver health care services to the poor was developed by the Social Security Administration (IMSS-COPLAMAR, which was renamed and now is IMSS-Solidaridad).

Shortfall

Because the government continually cuts funds to the public sector, there are two classes of health care, public and private. The North American Free Trade Agreement (NAFTA) with the United States and Canada is viewed as a treaty by the constitution and, once approved, will become "supreme law." This will most likely accelerate the process of privatization and, although access is a law, in reality it will decrease for those using the public sector.

Buildings (Hospitals)

History

Hospitals and clinics in the country were organized to help support a program from Social Security (IMSS-Solidaridad) that was established in 1979 to support the poor and bring services to previously underserved areas.

Present System

The hospital system covers as many as 13 million people in 31 states through a network of 3,200 rural clinics and 65 hospitals. The purpose is to provide clinic-based primary health care services and hospital care, especially for respiratory, gastrointestinal, and parasitic infections. There are several redundant health care systems in the country. The sectors of health care that produce these redundant systems are divided mainly by employment activity (government employees, teachers, social security system, and individual industrial groups) and fee-for-service private practice service. Each sector of health care has its own health care providers, hospitals, clinics, etc. A worker may belong to the social security health care sector but also to an independent one established by his or her organization. These fortunate individuals have a choice of which system to use.

Hospital Beds

There are only 1.3 hospital beds per 1,000 inhabitants, compared to 4.4 in the U.S.

Clinics

Each clinic is staffed with one physician, clinical assistants who are trained by IMSS, and workers who go out into the community. The assistants are bilingual and act as liaisons to the workers and to the community. The physician staff is mainly medical students with a one-year mandatory Social Service commitment.

Costs

Equipment

The private system buys its own equipment at the market rate. The public system buys what it feels it needs and can afford.

Health Care Providers

General practitioners' salaries have a very wide variation, depending on scope of practice and location. They can vary from $20-30,000 up to $200,000 and greater. The average seems to be around $50,000. Specialists probably average $100-150,000.

Insurance

Presently, employers pay 8.4 percent of total employee wages for disease and maternity insurance.

Patients

Patient pay in the public sector according to their ability, which will be defined by a social worker.

Drugs (Medications)

Approval Process

New medications in Mexico must be issued a permit by the Ministry of Health. It may be very strict but new drugs do not have the same standards imposed by the FDA in the United States.

Availability

The subculture of Mexicans who live on the U.S. border may frequently cross back into Mexico to obtain medications not available to them here. They may also illegally take medications into the United States. Some U.S. citizens cross into Mexico to avail themselves of clinics and medications not approved by the United States FDA. More medications are available over the counter (some antibiotics) but most medications are still controlled and can be obtained only by prescription from a physician.

Equipment (Technology)

Approval Process

Each system of care is responsible for its own technology. There are no restrictions on purchases from a federal or state level. Health care providers usually invest in and own the equipment they use and refer to.

Availability

In the private sector, if they can afford it, they can buy it. Public hospital equipment is funded by tax dollars, and there is usually a trade-off with other needs and wants in the health care systems. There are significant bartering and trade-offs in the public system.

Finance (Funding)

Government Financing

Almost the entire public system is financed by government tax revenues. Between 1983 and 1990, there was a decrease in funding to the Ministry of Health (50 percent) and to Social Security (61 percent). This has caused radical changes in service in the public sector, which mainly serves the poor population. Besides taxes as a mechanism for funding, the government depends on funds acquired from a percentage of total funds accumulated from the national lottery.

Private Financing

The government health care commitment is partially refunded by a commitment to the community by the recipients. The contribution by the villagers is in the form of latrine construction, attending health education classes, insuring child immunizations, etc. Since the late 1980s, private health insurance and premiums have become a source of revenue for the health care arena. Private health insurance companies would be a source for investment capital in other Mexican ventures. These funds are presently either diverted internally from other projects or obtained from external sources.

GDP versus GNP

GNP

Mexico spends 4 percent of its GNP on health care.

Per Capita Income/Spending

Private medicine is one of the most profitable economic activities in Mexico.

Health Care Providers (Physicians)

System of Care

There is no managed care. Most of the care is fee for service. The rural health care system established by IMSS-Solidaridad has been resisted by the traditional health care providers. The local clinics continue to use bonesetters, herbalists, spiritual healers, etc. There is severe unemployment among physicians, and some shortages have been eliminated by these physicians' working for IMSS.

Generalists

There are more general practitioners than specialists. Most health care providers are solo, with very few groups. There are some groups that share administrative functions only.

Specialists

Multispecialty groups, such as the Centro de Especialidad de Mexico (19 partners, with several subspecialties represented) in Monterrey are a rarity.

Insurance

History/Establishment

Prior to the 1980s, there was no private health insurance. Either the government paid on the public side or there was self-pay on the private side of medicine. In the 1980s, prepayment in the form of private health insurance was introduced to the health care system. The potential market is those individuals and families that earn six or more times the minimum wage (3.5 million families with 17.5 million members). The total Mexican market is estimated to be about 25 million people (25-30 percent of the population).

Benefits Package

Some insurance companies pay for certain tests and procedures only on an inpatient basis. This forces health care providers to admit more than necessary. There are no preauthorizations, no DRGs, and no RBRVSs.

Workers' Compensation

Workers' compensation is covered under the 24-hour health care protection afforded all citizens.

Jurisprudence (Law)

Torts

Malpractice lawsuit probability is very low.

Knowledge (Patient Information)

In rural areas, the Social Security system has funded access and health care delivery to the poor. The recipients of health care in these areas are committed to community participation as a means to help pay for their care. This helps them respect the value of the government investment in them.

Life Expectancy

Life expectancy for men was 66.4 years and for women was 72.9 years in 1990. By 1993, undocumented figures estimate males are up to 70 years of age and females to 73 years.

Morbidity/Mortality

Infant Mortality

Infant mortality is very high, 38.1 per 1,000 live births.

Morbidity

Mexicans are known to have a high prevalence of type II diabetes that presents in a younger population, and there is a higher prevalence of diabetic retinopathy and end-stage renal disease.

National Health Care Structure

National Medical Structure

The national health care system is under the Ministry of Health (IMSS) and the Institutes of Social Security (ISSSTE). The system has grown mainly through expansion of the social security system. All the important policy decisions are still made at a central level of the Social Security Department.

State Medical Structure

The country is divided into 31 states. There has been a movement to transfer responsibility for rural health care to the states and to continue funding by the Social Security Administration. By 1987, this move had occurred in 14 states and was stopped. Presently, the limbo status continues, with half of rural care run by the states and half by the SSA.

Community Medical Structure

In 1990, the government established a structure for community participation in health care under the National Program for Solidarity. IMSS-Solidaridad employs specially trained community action promoters (PACs) who rotate through various communities for one to two weeks at a time to train and help community staff. They also evaluate communities for other resources available for their betterment.

Options of Care

There is a subgroup of Mexicans who live on or near the U.S. border and receive their health care in both countries. Their access and quality are said to be better or worse than those of other Mexicans, depending on whom you ask.

Population

Mexico had a population of 81.1 million in 1990.

Quality of Care

Health Care Facilities

Certification by the government of medical schools and of their medical graduate and postgraduate degrees in much less stringent than that of its NAFTA partners, the United States and Canada.

Health Care Providers

Licensure is on a national basis (by state in the United States and by province in Canada). The license is granted by the Secretary of Health after the graduating medical school has passed the individual with its professional examining procedures and the title of "Doctor" has been granted by the Secretary of Education. All specialties now have board certification. In the future, a health care provider will only be able to practice in a specialty in which he or she is board certified. This will allow the National Academy of Medicine to better control quality of care.

Retirement

Employers are required to invest in their employees' retirement fund without matching funds from the retiree or employee. The tax withheld by the government is the SAR (systema ahorro para retiro).

Savings

There is no mandatory government level for savings. Hence, most disposable income is spent, and savings as a whole are very low.

Taxes

Income Tax

The maximum tax rate is 35 percent, on a progressive scale, but there is no state tax on income.

Social Security Taxes

All employees are required to pay a housing tax (Infonavit) collected by the Secretary of Social Service. This tax subsidizes the government housing projects.

Value-Added Tax

There is a value-added tax on all purchases.

University/Training (Medical Schools)

Medical Schools and Medical School Training

Physician training is high school (2 years after grades 9-12) followed by 6 years of medical school, of which the last three are in a hospital. There are 52 medical schools in the country.

Postgraduate Training

Everyone must do one year of social service upon graduation from medical school. Internal medicine training is three years, followed by subspecialty training.

Other Training

Health care executive training, a master's degree in health care systems, and quality assurance education are provided by the Advanced Education Program in Health Systems Organization and Management (PROASA).

Waste Disposal

One of the major problems in Mexico is disposal of toxic waste. Although strict environmental protection laws may be established, they are not strictly enforced. There are high levels of air, soil, and water pollution. X-ray, Laboratory, and Ancillaries Almost all MRIS in the country are private. They are bought and used by one of the health care systems. Monterrey, with a population of 4 million, has 7-8 MRIS in a 5-kilometer radius, while Mexico City has only 10-15 for a 20-million population.