KOLONIA, Pohnpei - Health care in the FSM has traditionally been a pretty good deal. Anyone, insured or not, could, and still can, go to any of the State Hospitals and expect to be treated. Payment for medical services has been made in the form of giving local food to a state hospital to include in its meals - in lieu of cash. In Kosrae in particular, this has not been an uncommon practice. Traditionally, the System has basically said: No insurance? No cash? No problem.
And in recent years, starting in the late-90's, the services and choices and quality of the health care system improved with the establishment of the private clinics in Chuuk and Pohnpei, the two most populated states of the federation. Yet, unlike the state hospitals, they are not subsidized directly by their governments, and make their profits almost entirely on the claims they bill to the MiCare health insurer each week, each month, each year. MiCare is the country's only nationally managed health care insurer, and by and large, the backbone of the health care system's ability to function in a self-sufficient and sustainable way.
MiCare currently counts about 20,000 people as members, onesixth of the FSM population. (Chuuk holds roughly 55,000, Pohnpei 35,000, Yap about 11,500, and Kosrae 8,500 local residents.) It's a low per-capita coverage rate by any reasonable standard. Most who are insured are government employees enrolled in the plan, paying 48% of the premiums, while the government pays the remaining 52%.
Private groups are also enrolled in the plan, sharing with their employees the same ratio of premium payments. The remainder of the MiCare membership constitutes a relative minority of individuals who sign up, paying 100% of the monthly premium for health insurance by themselves. The plan is optional, not mandatory.
The growing costs absorbed by the insurer are coming in large part from the billings of the private clinics for services and products rendered, which are then passed on to MiCare. To the point that MiCare is being crushed under the weight of medical claims from both public and private medical service providers, having over the last several years accumulated a debt of over $1 million. (Kosrae and Yap hospitals, according to a MiCare staff person, each receive set disbursements every three months to cover the variable number of patients they treat, and thus do not bill claims to MiCare.
Kosrae and Yap also have no private clinics, and rely exclusively on their single state hospitals to treat their citizenry.) MiCare came into existence in the early 80's, designed to work in tandem with the four state hospitals and various public dispensaries of the nation, whose focus was not so much on profits, but on providing a government service. But with the MiCare insurance teetering on the brink of financial bankruptcy - a recent $300,000 appropriation from the FSM Congress has helped somewhat - health care costs, like everything else in the enviornment of this nation's rapid commercial and consumerist expansion, will be going up.
MiCare's Administrator, Yosiwo George, says patients currently "don't feel" the expense of the care they actually receive, particularly from the private clinics. The bill for services, at both public and private medical providers, is unseen and unknown and goes directly to MiCare to pay. George, who came into the MiCare program as its Administrator last year, after a distinguished tenure as Kosrae's Chief Justice, is determined to make the plan solvent, and make it work. He stated in a series of interviews that he is committed to making this happen within another year through a twopronged approach. The first is a 10% premium increase to members. "The premium was structured in such a way that it could not cover it's own costs…but because of the financial situation now and the increased costs…we need to make it balanced, collect what we spend," George stated at the MiCare office which is preparing itself for the impending rate increase in March.
This is only part of the potential overall increase in cost to the members, the public at large, and the system as a whole. The other side of the equation to bring the beleaguered national health insurer back to respectability is the MiCare decision to revise what is known as the Relative Unit Value (RUV) fee schedule, a list that sets a cap on the amount public and private health providers can expect to receive from MiCare for the services they have provided, and then charged, to the public. Generally speaking, under the revised RUV, what providers can bill to MiCare for medicines, specialist services, surgical procedures, physical exams, and so forth, has decreased, and in a few instances, ceased completely. "This is a group effort," explains George, taking the long, big view of the entire system. "They (providers) need to be reasonable in their pricing."
Taken together, it's a high-wire balancing act, based on a very simple economic principle. On the one hand, MiCare is trying to control what it has to pay to the various health care providers by reducing the amount that public and private clinics can bill to insurance.
And on the other, increasing money it receives through higher premium collections. Increase revenue. Decrease expenditures. The fall out - to the patients, the consumers - will soon be determined, but the private clinics in the FSM, who quite often provide a cleaner, more efficient, and more modern service to clients, are already a little stressed over the announcement of a new RUV and forthcoming revised MOA's (Memorandum's Of Agreement, contracts that each provider affiliated with MiCare must negotiate and agree to). For example, will the private clinics have to charge customers out of pocket for patient services that will be curtailed by the new RUV? Will this result in less business?
The Pohnpei Family Health Clinic, Kolonia Dental Clinic, Genesis Island Family Clinic, MedPharm Pharmacy and Clinic, Sefin (Chuuk) Health Clinic, Chuuk Family Clinic & Pharmacy, the Micropharmacy of Chuuk, and to a lesser degree, the off-island providers in Guam, Hawaii, and the Philippines will have to readjust on how they operate vis-à-vis the MiCare plan and their customers. Providers have until the end of this month to sign the new MOA's and agree to the revised RUV fee schedule, according to a MiCare memorandum sent out on February 9, or have their current contracts suspended, requiring health plan "members…to pay cash upfront and seek reimbursement" from MiCare.
The clinics find themselves in somewhat of a quandary; a rock and a hard place perhaps. Turning away patients for an inability to pay, even for the private clinics, is nearly out of the question; losing patients is not good for business. Yet collecting money from patients is also, as one clinic owner explained, "very, very difficult." Conversely, charges billed to MiCare are guaranteed to be paid. This has led to the clinics in Pohnpei in particular relying quite heavily on MiCare as a source of revenue. Charging patients for care is not good for business; while all people need medical care, very few have the money to pay for it, and won't.
There is uncertainty at this point. "We can't just abruptly stop," says Dr. Merlynn Abello-Alfonso, on the necessity of providing continuing services to her patients at Genesis, a popular and well-run private clinic in Pohnpei. "We have a commitment to our patients and we have to see them. We can't say, 'We can't see you because you can't pay'."
Dr. Alfonso realizes the impending difficulties to people with limited incomes. "It's difficult to expect people to cope when salaries are frozen." Conversely, the life of her clinic, and the other private providers, is also an issue. "It's going to be a fight for survival," she admits, in the very clean clinic she oversees on a day-to-day basis. "We have to figure out how to go about it."
Certain realities must be considered. Are we continuing a trend of moving further from the socialized medicine of the past and inching toward medical services based on two classes: those that can pay, and those that cannot? Perhaps not, but it's hard to say at this point. From discussions with individuals that are key players in this scenario, the long-term goal is to provide universal coverage at an equitable rate, with the opportunity to choose amongst several providers, both public and private. But this is still a ways off. Right now, in terms of health care - indeed, across the board - the country is headed for some hardcore choices and higher prices. Like it or not.
Editor's Note: The preceding story is the first in a series that will examine and present the issues surrounding the FSM Health Care System, and some of the pivotal components and views within it. Primarily, we felt at the KPress that a series of stories on the subject will allow us to present a broader and more complete picture of the myriad challenges on an issue that is of paramount importance. And perhaps secondarily, there will be perspectives and developments that will emerge and will require followup after press time.