By John Carruthers, assistant editor, April 01, 2014
Mexico’s sizable population of long-uninsured citizens, and the move to rapidly enroll them in a new system of coverage, provided challenges to both physicians and policymakers when legislation in 2003 mandated universal coverage with a national insurance system. The country, having completed full implementation of its universal coverage plan in 2012, provides insight into the long, often-arduous process of extending care to tens of millions of uninsured. Mexico faces problems familiar to those watching the rollout of the Affordable Care Act in the United States — there is a significant shortage of overall physician workforce, uneven distribution of specialists, and an even more stark contrast in access between urban and rural patients.
Nearly all health care is run through state-level government agencies in Mexico’s 31 states, with funding assistance through the Ministry of Health at the federal level, according to Nuria Homedes, MD, DrPH, assistant professor of management, policy, and community health sciences at the University of Texas Health Sciences Center at Houston.
The health insurance options for patients in Mexico, Dr. Homedes said, are mainly divided between:
- plans for those employed either by the state or in the private economy — public insurance run through the country’s social security system;
- coverage via Seguro Popular, the universal coverage system created for those at the lower end of the economic spectrum; or
- privately funded and administered insurance plans, which are only affordable to approximately 3 percent of the country’s population.
Half of the population, both private and public sector workers in the formal economy, are covered by the first option; they pay into an insurance plan run through the country’s Institute of Social Security or the Institute of Security and Social Services for State Workers. Workers pay premiums that rise with their wages with their employers and the government funding equal portions of the remainder. These plans feature health coverage that includes prescriptions, as well as disability benefits, unemployment insurance, and other benefits. [pagebreak]
Much like how health plans work in the U.S., Dr. Homedes said, each plan in this system avails enrollees of the physicians and hospitals in its network. In addition to treatment at state-owned hospitals 31 percent of facilities, but 67 percent of total patient capacity, according to the Pan American Health Organization’s Health in the Americas — social security health plans also routinely contract with private physicians and facilities to care for enrollees, she said.
The second option, Seguro Popular, helps cover those in the informal economy, which Dr. Homedes said consists of a large number of traditionally uninsured in Mexico who were either unemployed or working in low-skilled, low-paying jobs that offered no coverage and did not qualify for coverage under either plan. This population makes up nearly 50 percent of the country. To cover them, the government created Seguro Popular. Families pay to join Seguro Popular at a rate based on their income, and are encouraged to make preventative care visits at community health clinics set up for this purpose as the country tries to lower costs by focusing more on preventive care access and utilization. Care is completely subsidized for the 30 percent of the country with the lowest incomes, while the rest pay a progressive premium based on their earnings.
In addition to these options, around 3 million people purchase private insurance, which ensures access to the highest quality facilities and physicians above and beyond what is available through either Seguro Popular or the social security insurance programs. The number is made up of wealthy and middle class Mexican citizens, as well as foreigners who work and live in Mexico with various international corporations. In addition, specialties such as plastic surgery, bariatric surgery, and dentistry enjoy a healthy amount of business from medical tourists typically Americans near the border and retirees hoping to save a significant amount on procedure fees. [pagebreak]
Financing and infrastructure
Physicians in Mexico are predominantly reimbursed on a salary basis, whether they’re a primary care physician or a specialist, according to the Organization for Economic Cooperation and Development (OECD). This, Dr. Homedes said, decreases the rate of patient visits — 1,494 per year per physician, according to the latest data available through the OECD, compared to 1,601 for the U.S. and to the OECD average of 2,357. Mexican physicians routinely work for a health network as well as a practice in the private sector to offer fee-for-service outpatient procedures to patients on a more rapid basis.
Since implementation began, the Seguro Popular insurance program has grown from under 10 million enrollees in 2004 to 52.7 million in April 2012, a number that represents universal enrollment for Mexico’s previously uninsured population. The health infrastructure also expanded greatly, with 15 specialty centers, 200 hospitals, and 2,000 ambulatory clinics constructed between 2001 and 2011, according to an August 2012 paper featured in The Lancet (see sidebar). Many of these facilities are funded by the federal-state partnership, and owned and operated by the state-sponsored health plans that serve the population, while a significant amount, according to Dr. Homedes, are privately owned and run facilities that attempt to attract wealthy citizens and foreign workers. The physician to population ratio increased 54 percent from Seguro Popular’s inception to 2010, with additional resources allocated to hospitals, regional clinics, and medical centers beginning in 2003 for the training and hiring of more physicians.
Despite the gains made in physician and facility numbers, Mexico’s decentralized system, where each of the country’s states is responsible for financing care within its borders, still results in a stark contrast in care access between urban and rural settings, according to anthropologist Matthew Dahlstrom, PhD. In addition, waiting times for those on the national plan can pose a burden to patients.
“The quality of care can be as good as or better than the care in the U.S., however it is not consistent throughout the system. Quality of care is largely dependent on where people live and whether they are using the public or private system,” he said. “If they live in large cities and have private insurance then they can expect some of the best care in the world. If they are on public insurance, as almost the entirety of the country is, they can expect to have limited doctors, long waiting times, and might have to bring medication or supplies to the hospital.” [pagebreak]
Access to dermatology
To see specialists such as dermatologists, patients who are covered by either Seguro Popular or state-sponsored private insurance must first see a primary care physician and then receive a referral to a specialty clinic affiliated with the program. In practice, Dr. Dahlstrom said, this resembles the health maintenance organization (HMO) model in the U.S. Wait times can be long, according to Dr. Dahlstrom, because of both high demand and the longer average length of visit.
“There is less emphasis on expensive diagnostic tests and more on spending time with the patient,” he said, pointing out that access to testing is often non-existent outside major metropolitan areas and can be severely backed up where it is available. Diagnosis, he said, is often made through collective illness narratives, where the physician attempts to make diagnoses through the patient’s records and their description of the symptoms, and prescribes treatment in very basic terms. Patients who have received a low level of care for their entire lives often have a difficult time following any but the most basic prescribed treatments, Dr. Dahlstrom said.
The wealthiest 3 million citizens, Dr. Homedes said, receive direct access to specialists and private hospital facilities through their health plans, or can achieve access though fee-for-service payment to private facilities. In some cases, she said, patients covered under one of the state-sponsored social security programs are able to directly access this level of care via a negotiated agreement between their plan and certain private facilities and specialists. Seguro Popular, on the other hand, covers a smaller range of interventions than private payment, private insurance, or the social security plans. Patients must be referred, and often face long waits, except in the case of emergencies. Dermatologic conditions almost never result in emergency treatment in Mexico. [pagebreak]
Access to dermatologic care is impeded by the relatively low supply of dermatologists in the country. The Academia Mexicana de Dermatologia (Mexican Academy of Dermatology) directory lists 403 dermatologists to serve the entire population, a ratio of one dermatologist per 294,000 residents. (The ratio in the U.S. is approximately 39,286 residents per dermatologist.) Further, the workforce is concentrated in a few cities, with over 53 percent of dermatologists in the country split between Mexico City, Guadalajara, and Monterrey. (The metropolitan areas of the three cities combined account for 24 percent of the country’s population.)
U.S. dermatologist Sasha Jazayeri, MD, who volunteered with the Mexican Red Cross in Guadalajara, said that the availability of specialty skin care in Mexico for those located outside of major urban areas is extremely low, and that follow-up care can prove difficult as a result. “The challenge was not being able to follow up with patients who traveled long distances to Guadalajara, as there are very few dermatologists compared to the demand,” Dr. Jazayeri said.
Availability of treatments
Recently, dermatologists and patient advocates in Mexico petitioned for expanded drug coverage for psoriasis, which affects 2.8 percent of the population. The Fundacion Mexicana Para la Dermatologia (Mexican Foundation for Dermatology), a sister patient advocacy organization to the Academia, reported in October 2013 that 55 percent of psoriasis patients in Mexico reported social disruption, 37 percent reported limiting their daily activities, and 20 percent reported long-term emotional damage as a result of the disease. Patients covered under private insurance or one of the state-sponsored private insurance programs have access to a broad range of treatments for psoriasis, including phototherapy, biologics, and systemic treatments, while those under Seguro Popular only have access to topical medications.
While psoriasis is a high-profile problem among patients, there are also many more cases of acute and chronic systemic and cutaneous infectious diseases, according to Dr. Jazayeri, including tuberculosis, cutaneous leishmania, dengue fever, and parasites.
Dermatologists in Mexico are organized through the Academia, a non-profit organization founded in 1952. The organization’s elected board organizes educational meetings and courses over a two-year calendar and publishes the Mexican Academy of Dermatology Gazette. To join, dermatologists must participate in a scoring system that awards points for attending meetings, joining local societies, and presenting cases at conferences. In addition, the Fundacion promotes public education and lends its support to products under an official endorsement.
Mexico at a glance
About the contributors
Nuria Homedes, MD, DrPH, is an assistant professor of management, policy, and community health sciences at the University of Texas Health Science Center and the co-director of its Global Health Program.
Matthew Dalstrom, PhD, is an assistant professor of anthropology at Rockford College in Illinois who specializes in medical anthropology and Latin America.
Sasha Jazayeri, MD, is a private practice dermatologist in Phoenix who has volunteered in the most underserved areas in Guadalajara with the Mexican Red Cross.