A growing number of patients of the Muface system, a publicly funded mutual that covers the medical care of almost 1.5 million government employees and their families, are opting out of private health insurance offered by the government and preferring to be treated in public health care system when they get older and are diagnosed with serious illnesses such as cancer. This reveals a study carried out by members of the Department of Quantitative Methods in Economics and Management at the University of Las Palmas de Gran Canaria, the first to analyze hospital discharges for this group. Overall, the number of Muface-protected people choosing public health care has increased by more than 10,000 people a year since 2006, according to entity reports.
Muface is mandatory for civil servants, although once enrolled, the insured have the option to choose each year between private medical insurance (Adeslas, Asisa or DKV) or public health care. Although fewer and fewer, the majority choose the first option — which means paying a fraction of the fees — mainly for two reasons highly valued by the group: the ability to freely choose a specialist doctor without going through primary care help and avoid waiting on public health lists. In Spain, there are two other similar mutual societies that serve the military and judiciary personnel (Isfas and Mugeju).
The study examined more than a million hospitalizations in public centers of the community of Valencia between 2010 and 2015 from the Minimum Core Data Set (CMBD), a registry that includes information on all public health admissions. This allowed the researchers to compare the pathologies suffered by Muface patients who chose public health (7,264 people) with the rest of the population treated with the conventional health card.
“What we saw is that among Muface patients treated in public hospitals, there were more cases of lymphoma, cancer and tumors with or without metastases than would be expected. On the other hand, less serious diseases have a lower prevalence in this group than in the rest of the population,” explains Jaime Pinilla, one of the two authors of the study together with economics professor Beatriz González López-Valcarcel.
The prevalence of lymphomas was 176% higher among Muface patients treated in public hospitals than among the general population. For solid tumors with metastases, this increase was 57% and 48% for cancers overall. In contrast, mutualists had a lower prevalence of diabetes with complications (52% less), obesity (43%), chronic obstructive pulmonary disease (33%) and hypertension (14%).
Since there are no other reasons to explain these differences – the prevalence of these pathologies is homogeneous throughout the population and the comparison is made between people of the same age, sex and place of residence – the conclusion reached by the researchers is that there is a flow of public servants who, when suffering from more serious pathologies, more often with the age of the person, give up private insurance and prefer to be treated in the public health system. This means that those who stay in private hospitals have the opposite profile: less serious and milder illnesses.
“This is a conclusion we reach by deduction because we would need access to information about patients treated in private hospitals, which is something Muface does not offer. But the quality of the data studied and the method used, a quasi-experimental observational study in which for each mutualist we have chosen at least one non-mutualist with the same characteristics as the control, makes us think that the conclusions are robust”, he states.. Jaime Pinilla.
Data included in the survey and others provided by Muface show a trend that has remained constant over the past 15 years: more and more mutual members are choosing public health care, although the majority continue to choose private insurance. The total number of people covered has remained stable at about 1.5 million people, but those opting for public health have increased since 2006 by 183,000 people, and those choosing private insurance have fallen by 217,000.
Currently, 26.7% of total members choose the public system, almost double the 14.1% who did so in 2006. Even accounting for the natural evolution of this group—deaths, new additions…—these data shows that each year there are over 10,000 government employees who put public health at the expense of private.
According to Muface, who recalls that the vast majority of mutual insurance members continue to choose private insurance, part of this change is due to the new generations of public servants who, although not numerous – as of 2018, about 26,000 entered the mutual every annual media—are much more audience-friendly and split almost equally between the two systems.
But most notable in terms of health are the elderly, traditionally much more loyal to private health insurance. The most relevant data is how the increases that occur each year in the number of pensioners are distributed between public and private health care, a group of increasing importance due to the high average age of the general members (about 50 years, five more than the general population). Analysis of data from this group reveals that if a decade ago this increase was as high as 80% for private insurance and only 20% for the public system, these percentages reached 54%-46% in the last full year (2021). According to preliminary data from Muface for 2022, three out of four have gone public this year.
“The conclusions of the study, which can be extrapolated to the whole of Spain, have very important economic implications if we consider that most health costs are concentrated in a small group of people, between 5% and 10% of patients represent more than 50% of the total expenses. If a significant proportion of these more complex patients end up in the public health system, there is an obvious imbalance where it takes on more complex and expensive processes, while the private sector tends to stay with the lighter and cheaper ones,” says Jose Ramon Repulo, professor of health planning and economics at the National School of Health.
This fact puts the focus on one of the main arguments used by defenders of the Muface model: that the system represents savings for administrations, since the public costs allocated to each member are lower than those allocated to the average population. According to the report Private healthcare, adding valuepublished by the IDIS Foundation — an organization that unites the private health sector — the average price for each patient in public health amounted to 1,464 euros in 2020, while the average price of Muface premiums was 917, 37% less.
“The idea that Muface represents savings has been strongly defended by proponents of the model. But the truth is, we don’t have any studies to prove it, and the new study is particularly important because it’s the first to provide evidence. And they seem to show that public health care carries very important costs for Muface patients that private insurance avoids. This is a very important issue because mutual societies are also financed with public funds and maximum transparency is needed to investigate and improve their fate”, says Sergio García Vicente, member of the board of directors of the Association for Economics and Health (AES ).
The key question at this stage, on which there is no published research, is the reason why employees decide to switch from private to public assistance. The study’s authors concluded that “private insurance companies could send messages or signals about the quality of their care to the beneficiary in serious and expensive processes, which would lead to active risk selection.”
Risk selection is the process by which companies tend to avoid more expensive patients and favor those with better health. “Sometimes these mechanisms can be subtle. It is enough to make a seriously ill patient somehow see that he will be better cared for in a public hospital or to put up obstacles that delay or make access to services and treatment more difficult. But other times they are structural problems. The personal part of Muface works well for simple procedures performed by a single doctor. But if you have a complex disease that requires multiple specialists and going through different chains, patients face an odyssey of procedures and counters in management that is out of date. State hospitals have advanced more in the integrated care of various specialties with state-of-the-art services,” defends Jose Repulo.
The findings of the study are not shared by the private sector. Juan Abarca, president of the IDIS Foundation, described them as “very biased.” “The authors limited themselves to a retrospective study of patients from the community of Valencia over several years, but only those who were treated in public health care. Therefore, they do not know everything that happens in private. We, as health care providers, are not interested in patients going to the community, even to the complexes. Our goal is to offer comprehensive assistance to the entire group. It doesn’t make sense to think that we want to get rid of 10 or 12 patients or that there is risk selection,” he says.
According to the sector, the important thing is to “guarantee adequate financing through premiums, something that has not happened in recent years”, which has prompted several private medical insurance companies – Sanitas, Mapfre, Caser. …— abandoned Muface, considering that it was not profitable for them. The Ministry of Finance approved late last year to allocate 3.521 million between 2022 and 2024 for the Muface agreement, with annual premium increases of 8% to 10%, depending on the year.
The existence of Muface, Isfas and Mugeju, a system that does not exist in any other European country, is the subject of frequent disputes between its defenders and critics. The former defend that it is a decades-old model, that it is an acquired right, that it saves the state money, and that the public health system will not be able to absorb the nearly two million people protected by the three entities. Detractors argue that mutuals are a parallel health care system that privileges public officials and violates fairness, that the supposed savings are not there if public health care ends up taking care of the most serious cases, and that with the money the state gives these mutuals companies can strengthen public health to serve all citizens.
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