Public health pays increasingly higher bills to insure their professionals and face the compensation caused by involuntary errors and negligence. The 16 autonomous health systems with their insured health – all except the Canary Islands – are in serious trouble to renew their policies with the large insurers, which demand more and more money to cover the civil liability of doctors and are leaving public contests in some autonomies The yard is in turmoil and the global bill already amounts to 65 million, increasing the cost an average of 27% in three years after the last renewals of policies, according to sources from the insurance sector.
The reasons for this rise are several. On the one hand, the new scale for traffic accidents of 2016 – reference table used by judges for medical errors in the absence of a specific law – establishes higher compensation for serious cases. But, in addition, the demands have grown due to a greater awareness of the patient to litigate and the processes are perpetuated by the resources, which causes more legal costs.
In the last two years, traditional companies such as Zurich or Mapfre have abandoned the autonomic Executives – all except the Canary, who chose to avoid insurance and pay after each lost trial – because the business stopped being as profitable as before, and new insurers have entered, most of them foreign, like Berkshire Hathaway. "To avoid this dangerous dynamic of escalating prices, the Government must set the rates of compensation by law and thus avoid the sensitivity of each judge to errors," censorship Francisco Miralles, general secretary of the State Confederation of Medical Unions. The previous PP government left in the pipeline the development of the compensation Act and the current one is still working on it.
Medical errors are inevitable in a system that performs four million surgical operations each year. Óscar Sánchez, 42, underwent a gastric bypass in 2013 at the Reina Sofía Hospital in Murcia to stop his morbid obesity, but the operation caused him serious neurological damage. "Today he is disabled with one hand, he needs a walker to walk and his head has a regular one," says his mother, Carmen Ibáñez. The compensation paid by Mapfre was 500,000 euros.
With an ever-increasing workload, says Phillipe Paul, executive director of the French insurer Sham, which covers Catalonia, Madrid and the Basque Country, "medical civil liability in Spain is at a crossroads. We have a problem of profitability, "he admits. Meanwhile, the historic insurer Zurich has taken a step back: "We continue to insure the public administration, but we reviewed a couple of years ago the insurance related to medical liability to rebalance our portfolio and reduce our exposure in lines of business with instability in the long term ", explain sources of the firm.
Until 2002, when the national health service Insalud broke up in 17, the Ministry of Health paid an annual policy of 18.5 million to the insurer Zurich. Since then, the escalation has been unstoppable and in recent years has increased from 50 to 65 million. Some communities renew their insurance year after year and others for longer periods.
The rise in prices is also noticed by doctors in the annual payment of their collective policies of professional associations, which they can hire to reinforce their protection against possible errors. "Although it is not always the malpractice of a surgeon," adds Paul, "it also adds technological evolution [problemas originados por nuevas prótesis, entre otros] and the organization. "
The most palpable evidence of the current crisis in the sector are the public contests deserts, which have suffered communities such as Galicia, Andalusia, Aragon and Murcia, who have seen how no company bid to insure their doctors. The solution has always been to get a second offer greedier. Aragón, for example, offered at the beginning of the year a policy for 3.1 million – already elevated from the previous 2.6 million – and even then, no company bid.
If the policy that pays the Community of Madrid amounts to 12 million annually, the one of Andalusia supposes at least 15 million and the Basque Country adds 5.5 million. Catalonia pays 22 million and has a mixed policy formula, which includes the insurance of the four medical colleges, so the total amount adds up to 140 million in four years. When some health system has doubted if it could face the economic effort of paying more expensive policies, the doctors have protested to feel unprotected and the regional governments have turned back.
A Sevillian doctor defendant explains the bad taste of mouth that these litigations leave, even when the reason attends them. "The Andalusian Health Service never tucked us in, no one has addressed any of the five doctors in seven years of trial, even though we did not come to trial because there was good practice. I have a very calm conscience ", explains this doctor who demands anonymity.
The death of a man in the Emergency Room of the Virgen de Macarena Hospital in 2012 led to the criminal prosecution of his family against five doctors in the service. After several court records in the first instance, the Seville Court decreed that a trial should be held to determine what happened, but the insurer agreed to compensate the victim before the hearing, so it withdrew the claim minutes before the trial, the past January.
The overall figure of negligence and medical errors is difficult to quantify. Most regions have refused to provide it to this newspaper, as well as medical unions. "We have asked all the communities, but the Administration has a hard time being transparent," criticizes Miralles. But insurers certify the increase in litigation in these cases. As an example, the health of the Community of Madrid had 238 medical errors in 2018 that resulted in compensation of 6.6 million, according to the regional government.
"Despite the increase in prices, public health does not waive insurance because of the worsening of things. If they do not pay via premium, they will end up paying via indemnities ", values Francisco Sánchez, director of Health & Pharma of the broker Aon Spain. Diego de la Torre, of Willis Towers Watson, another intermediary, adds: "There is a market and that is the positive, we must adapt that offer to the premiums that can be paid. The market is volatile, but there is a market. " And Óscar Noguerón, of the Marsh brokerage, concludes: "The adjustments of costs in the public sector, added to the high accident rate has led to new systems and new markets."
AIG has already advanced that this summer he retires from Andalusia because the numbers do not come out. "The policy of AIG has an extension until June (…) The workers of the Andalusian Health Service will never be left unattended in their civil responsibility," reassure sources of the Board. Any involuntary error entails a professional and other patrimonial responsibility, both covered by the health service policy, which complements the insurance of the official medical school paid by each physician.
The insurers try to minimize the financial risks, but also that the health services learn from the errors and these are corrected. To do this, they try to refine patient safety plans and work hand in hand with the training and prevention departments. The Government of the Canary Islands has refused to explain why it chooses not to insure its doctors and if it is a profitable option.
"The companies have said I am retiring to the barracks because it was already difficult to secure the claims, which take a long time to resolve. Above now we have an uncertain legislative framework and compensation grows ", censor sources of the sector, which assure that the profitability is null because the cost of compensation exceeds what is paid by the policy. How can the new foreign insurers accept the challenge of losing money? Where is the business? "It is unquestionable that money has been lost, but having 10 million in hand helps you to have financing and invest."
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The multiplication of demands of patients before possible medical errors has a direct consequence: in a preventive way, many doctors perform tests only to treasure arguments before the judge in case of being sued. "Defensive medicine is a factor in the growth of health spending, especially in the United States but also in Spain, which consists of carrying out more tests than strictly necessary to be more certain of the diagnosis and then prove in the courts that their behavior has not been negligent. ", explains Félix Lobo, Health economist at the Carlos III University of Madrid. "A possible remedy would be the protocolization of medicine, but often the judges seek to eliminate the risk completely and this is a very serious error and above all it is very expensive, it is not worth it", illustrates the expert.
A study with 1,449 emergency department physicians surveyed in 2017 showed that 89% of the physicians admitted carrying out diagnostic tests of "doubtful utility" to prevent further claims and compensation. To what is due? Doctors attribute it to the perception, shared by 91% of respondents, that "judicial pressure has increased" in recent years. In parallel, 63% of the doctors said that they extend "unnecessarily the length of stay of patients already diagnosed" for prevention of possible legal obstacles.
It is revealing the perception of the doctors on whether hospital managers cover their work in the emergency room when a problem arises: 88% consider that the protection of health structures protects them little (59%) or none at all 29%). Is it necessary to strengthen the medical-legal training of doctors? 96% answered yes. The survey was commissioned by the Collegial Medical Organization, among other organizations concerned about the rise of defensive medicine.