First Chilean impressions: IT'S SUMMER!!! Every single day the weather is the same: clear blue skies, bright sun, 85 degrees, 0% chance of rain, and sunset at 9pm. Couldn't be better. Also an extremely modern city, especially by Latin American standards. There is a very functional and clean subway and bus system. All the highways are wide, fast, and new. They go up on elevated bypasses and through tunnels that rival Boston's big dig (not that that's a particular achievement, so let's say Chile's compare very favorably to Boston's big dig). Normal, orderly traffic laws apply. I would actually feel comfortable driving here.
What have I been doing here? So far I am spending 2 weeks with students from Harvard's School of Public Health who are here for an intensive course studying the Chilean health system and the outcome of its reforms. The course is amazing. We have met with important leaders from the Department of Health, the parliament, the major newspaper editor, hospital and clinic directors, presidential candidate's health pointpersons (there's a huge presidential election this upcoming Sunday), mayors, etc., and have toured medical centers at every level of the system. Everywhere we go we get a 5-star reception. The biggest highlight was a trip to the parliament, where the president of the chamber paused business to welcome us, the health committee convened a special session to speak with us and answer our questions, and we were then invited to a first-class meal in the parliament's club room overlooking the Pacific coast (where we a choice on the menu was the luxurious delicacy of cow tongue).
So, what have I learned about the Chilean health system? It's actually a really interesting system. It's a mixed public and private system. Everyone who earns money, whether salaries or retirement pensions, is required to contribute 7% of their income to health insurance. They can choose whether they want FONASA--the public insurance, or they want to opt out of public insurance and choose an ISAPRE--competitive private insurers. FONASA is divided into 4 categories based solely on income which determine how much, if any, copay you have to pay for medical services. Age, medical history/risk, and other factors have no influence on what FONASA you get, so all categories of risk are effectively pooled. ISAPREs have lots of options with different benefits, and you may have to pay a higher premium if you are a high-risk patient. Depending on how much 7% of your particular income totals, you may or may not contribute enough to afford an ISAPREs premium, so you may have to add more money out of pocket to the base 7%, or you may choose to add more money to get a more comprehensive plan. This means that generally the rich opt for ISAPREs, which covers about 14% of the population, while the other 75% of the population's 7% tax contribution isn't sufficient for them to move from FONASA to ISAPREs. Only about 4% of the population is uninsured, and in contrast to the United States where many uninsured are indigent, these 4% are almost all people who can afford healthcare but choose to take their chances and pay out of pocket when expenses arise (i.e. the very, very rich). Since nearly everyone has some level of coverage, Chile has been able to achieve high health indicator levels including a high life expectancy (less than 1 yr difference from the US) and low infant mortality rate.
Next, there are both public and private healthcare providers (clinics, hospitals, physicians, etc). The public system is very much like an HMO. Regional clinics serve as gatekeepers where patients must be seen in order to obtain more complex or specialized consultations, diagnostics, and treatments. These clinics are financed by the government, which provides a per-capita payment for each patient who is enrolled. However, the public system often does not have enough capacity to meet all the FONASA demand, and long waiting lists exist. Therefore they may transfer some patients to private clinics, which operate on a fee-for-service basis. In that case, FONASA pays a pre-negotiated amount to the private clinics for the services that they were unable to provide in the public system (the only case where government funding goes to the private system), but the patients pay the same copay as if they had been treated in the public system. (Side note: one of the reasons for limited supply of services in the public sector is that healthcare professionals working there are considered government employees and as such they receive a fixed salary no matter how many patients they see, and they essentially cannot be fired, so there is no incentive to work harder or increase efficiency.) FONASA patients also have the option of buying vouchers which entitle them to go directly to private clinics without a referral. The voucher pays for a specific encounter and can be for a doctor's appointment, a CT scan, or even a surgery. Surprisingly, about 54% of private clinic's patient encounters are with public FONASA patients through either the referral or voucher systems. We toured a private hospital and it was better than the nicest parts of the nicest American hospitals I've seen. Every room was private, every room had video and heart monitors, and there were even separate hallways for patient transport to maintain patient privacy and dignity. They were at 92% bed capacity the day we visited and no one appeared harried or flustered. The whole place was peaceful, clean, and appeared brand-new and state-of-the-art.
Another reform from 1981 is the family health model, where patients are treated in a biopsychosocial context by a multidisciplinary team that includes doctors, nurses, psychologists, and social workers. It views the patient within their family and environmental context, and treatments include techniques such as meeting with the entire family together and making home visits. 
They also make complex and extended family trees that include all risk factors, even social factors such as which members of the family are close friends and which hate each other's guts. Some of the centers we visited had electronic medical records, but in another regional center they tied little pieces of colored yarn onto the charts to color-code different risk factors, and they tracked all the risk factors and all the actual diseases present in their population.
The newest Chilean reform is the creation of the AUGE-GES. This is a list (currently at 56 but projected to reach 80) of pathologies for which the government guarantees specific diagnostic/treatment access, protocols, and promptness for a single cost for both public and private systems. In theory these are the diseases that are most common and for which treatment is most cost-effective. Using adult-onset diabetes as an example: within 45 days of a doctor suspecting a patient has diabetes, the patient should be evaluated by a nurse and a nutritionist, and should have blood and urine exams. Within 24 hrs of confirming the diagnosis, treatment should begin. Within 90 days the patient should see the endocrinologist. There are also reduced copay levels included in these guarantees. Sometimes the guarantees are limited by age, for instance the copay discounts for diabetes are only for people less that 60 yrs old while all the guarantees for arthritis are only for people over 55 yrs old. One of the goals of AUGE was to reduce the waiting time. However, given that the limits of financing and human resources have not been changed, the unforseen side effect of AUGE is that it has reduced waiting time for AUGE diseases, but has dramatically increased waiting times for people suffering from all the myriad other non-AUGE conditions, since AUGE conditions are treated preferentially in a race to meet the legal time limits. One deputy (like a Representative) with a surgical training gave the example that in the hospital patients with gallstones (AUGE) all have real beds and get quick surgeries, while patients with life-threatening conditions requiring emergent abdominal surgery are laying on cots in the hallways waiting for surgery. Also interesting about AUGE is that it was passed with a "Risk-Equalization Fund" for all the private ISAPRES insurers, which requires them to redistribute profits based on the risk profile of their insured population only for AUGE diseases. Therefore an insurance company that effectively enrolled only low-risk clients will have to give their money to other insurance companies who have more clients with AUGE conditions to "equalize" the playing field, which basically destroys competitive market forces in this formerly fully private system.
Starting next week, I'm going to see all these systems in action while I work in one of the University-affiliated private hospitals doing a surgery rotation.
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