|The Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)|
|2. Development of the social security institute|
The Social Security Institute of Costa Rica has been using different health care models since 1974. The industrial physician (i.e., a physician hired by the employer to work at the job site) was proposed in response to the reasonable argument of employers regarding the time it took for their workers to visit a social security clinic. Under this system, the employer pays the salary of the physician, the Institute provides the remaining benefits required by the worker, and the latter is able to receive adequate care on the job site. This means less time lose in productivity and more profits for the employers, and a better relationship with their workers. From the beginning the results were impressive, since all the parties involved were satisfied with the system. To date, there are more than 800 urban and rural enterprises that use this system, and in some instances even retired workers or dependents see the physician on the job site of the direct beneficiary. In 1992, this system was responsible for more than 700,000 medical visits that are now being complemented with a rapid delivery system of medicines on the job site.
The model of mixed medicine was created in 1989. Under this system, the beneficiary can choose the physician of his preference and pay him directly for the services provided. The beneficiary pays the physician directly and is not reimbursed, and the Institute provides the complementary benefits thee the case requires. The results of this model have been positive, although not as good as those of the previous model discussed. The costs of this system are greater, since the physician provides diagnostic and curative services that are also provided by the Institute. About 125,000 medical visits were covered by this system in 1992, and more are expected in the future.
The "English model" was introduced in 1986 in a city of 20,000 inhabitants who previously had to receive health services in another city. Under this system, a group is formed to become responsible for the health care needs of individuals in a population who are allowed to choose their physician from the group formed. Patients are allowed to change physicians if they desire to do so. The income received by the physician is based on the number of persons enrolled under his care. The ideal situation for the physician is then to have full enrollment but not to have patients who need his services frequently, since his income is based on enrollment and not on actual number of visits. This fosters the preventive approach and the development of trust between the patient and his physician of choice. The persons enrolled under this model have the right to request emergency services beyond conventional hours or days of operation and may even request to be seen at home. In addition, the physician has the obligation to visit and familiarize himself with the environment in which his patients live.
The initial results of this system were not satisfactory, mainly because the physicians did not perform the role that was foreseen for them. Even though physicians were trained for the health system, they lacked training in the skills necessary for the development of this program. However, the subsequent application of this program in a community of 30,000 people has yielded excellent results. Experience shows that the incorporation of the community medicine approach in medical schools is an essential seep that needs to be taken for the success of this health care model. This system accounted for about 150,000 medical visits in 1992.
In 1987 a clinic was built in Pavas, a city of 60,000 people that included outpatient, diagnosis, and special treatment services. It was decided to test an integral health care model in this population, an effort that was coordinated by a cooperative that was contracted and supervised by the Ministry of Health and the Social Security Institute. The results could not have been better; the level of satisfaction and organization of the community reached levels never attained before. The personnel of the cooperative in charge of operations also attained a level of satisfaction not observed in the traditional model. This experience was repeated the following year in a community of about the same size but with a different socioeconomic composition. The results were as good as or even better than those in Pavas. The two locations accounted for more than 300,000 medical visits. At this moment there are two additional cooperatives being formed to cover additional populations with this health care model. By 1992, this system, which falls within the model of subcontracting private services, accounted for 15% to 17% of the services provided by the Institute.
In 1987, the Family Physician specialization was introduced as a community model. However, there were many difficulties in developing this idea, because it was perceived as a competitor for ocher specialties. Nevertheless, its performance has been excellent and its expansion will have a strong impact.
In spice of its achievements, the health care model of Costa Rica is at present undergoing revisions and a complete structural reorganization. This is to be expected, since the profound changes that have occurred in our societies force the modernization of organizations all over the world. It is expected that the new concepts will reinforce the increasing social value attached to individuals and will make available a good quality of life to larger segments of the population.