Miércoles 26 de Noviembre de 2014

Informe Sintetizado

According to AGN, PAMI has "unexplained deviation of funds"

The audit examined the ophthalmological services of the health care company and not only found flaws in the regional offices, but also in the professional’s work. The equipment necessary for complex procedures were missing, there were complaints about delays in shifts, and some health care providers maximized their revenue by addressing fewer patients than they had to.

 

El alcance del control de la Unidad de Auditoria Prestacional es escaso.
Hay desvíos que involucran la calidad en la prestación a 121.053 afiliados.

Miércoles 24 de Julio de 2013

According to a report by the General Auditor’s Office (AGN), the ophthalmological services provided by PAMI during 2010 recorded "unexplained detours". The failures appeared in several of the 36 Local Management Units (LGUs) that the health care company has throughout the country, this also emerged after analyzing the work of some of the 348 providers, ie professionals, habilitated to serve over 4.1 million affiliates nationwide.

The Providers

PAMI, or the National Institute of Social Services for Senior Citizens and Pensioners, has the responsibility to control, through the Providers Audit Unit (PMU), the "relevance, effectiveness, scope, quality, and timeliness of medical benefits, and to verify the level of satisfaction the affiliate has", explains AGN.

The report states that the problem was that "the scope of control the PMU has is scarce," adding that this is seen in the fact that "during the year under review (2010), field checks were made only in 5.46% of providers, or 19 out of the 348 total number of providers. Moreover, these controls were performed on only six UGLs out of a total of 36 (16.66%)."

Despite the limited samples under analysis, the auditors highlighted some "deviations" that were found in the reports given by the PMU of PAMI itself. They involve the quality of health care providers to over 121,053 members. For example, "at the Burzaco Eye Center, considerable deviations were observed in the locations as well as in biosafety. Lack of equipment and highly complex practices are referred to other centers that have no authorized provider agreement. "

A curious fact is that the survey could not assess the equipment used in the Burzaco operating rooms because "they bring the equipment in on the day the procedures are performed." This means that all the apparatus is there only when operations are being performed. Moreover, in the Devoto Eye Center "a downgrade in quality, diversions and sterilizing surgical areas, and there are delays of up to 30 days in appointments for pre-surgical studies," this can be observed in the report published this year.

As for the control in the offices of PAMI, AGN discovered a "mismatch": "The PMU does not have data for the respective activities of the Audit Department or the Provider Division of each LGU’s incongruous situation, because there is a resolution that links them together".

To complete the picture, "Management of Medical Care and LGUs have not provided (to the Audit) data that would demonstrate control in care quality, location, structure, functionality, biosafety, human resources, equipment, and technology as well as other obligations assumed by providers, " states the report. 

Logically, within PAMI works an Internal Audit Unit which works in terms of operative plans approved by the Comptroller General's Office. In that sense, AGN says that for the years 2010 and 2011, "their internal Audit has not performed audit work relating to the Provision of Ophthalmic and Optical Services provided by the Institute."

Appointments

Moreover, the inspection agency wanted to know how they meet current regulations regarding the delivery of care shifts for ophthalmological services. From this point forward, we examined the work of eight LGUs and found that the "average delay in the granting of appointments was 29.21 days", when it is assumed that consultations should be scheduled within no more than seven days.

Moreover, in cases in which members called to make an appointment "the call center only gave appointments to 22.45% of the calls", while only 7.89% of the professionals gave the consultations on schedule.

These irregularities are also replicated in the telephone service: "PAMI listens and responds." AGN noted that "in 2010 there were 1,284 claims, being the most problematic: the delay in providing appointments, with excessive delays, or reallocation of shifts (58.87%), complaints for poor work (13.70%), and complaints for failure to provide medical services(5.68%), among others. "

Furthermore, the regional offices with the "highest incidence of complaints and claims" in that year were the management units in the Capital and in the City of Lanus, in the Province of Buenos Aires.

The Providers

As for the professional’s performance, AGN defined a Handbook for PAMI’s providers. In short, it indicates providers how they should serve the members and how those services will be paid to providers.

According to these rules, and after the health care company establishment the value per capita, which means how much an affiliate costs, the providers charge by the number of patients assigned to them, and not the actual number of people they treat.

Professionals also have two other sources of income: first, the extra that comes if they give PAMI statistical date and, also, an incentive for each effective treatment they provide.

And the picture is completed with a concept called the "expected usage rate," which is set by PAMI for each Local Management Unit. AGN also found deviations in this matter: for example, in the Capital City location, the expected usage rate was of 1255.03 patients, but is serving 219 per month, generating a negative deviation of 83%.

In the opposite direction we can observe for example, that a provider of Mar del Plata has an expected prevalence rate of 499,30 patients, it appears that 2,814 members attended, exceeding the average by 464%.

Furthermore, the findings of AGN shows that "deviations" that emerged after comparing the performances of the various Local Management Units "have no explanation from the epidemiological point of view", but could find sustenance from the following causes: under provision as a mechanism for the provider to maximize revenue, misinformation about obligations performed by the provider; the data provided to PAMI was found in a deficient manner,  and an overflow of affiliates that are sent to a providers that cannot treat them accordingly. The audit report has a special section on cataract surgeries performed by PAMI.

Research says that "on average, for every 739 affiliates one cataract surgery is performed, at least throughout the time the audit was being carried out. However, the report explains, "in this average there are cases with very large variations, such as the case of a provider of La Plata, who performs surgery every 154 members or, in the opposite direction, the case of a provider of Junín, which performs a surgery every 8,134 members”. We must also consider that there are providers who do not report on the surgeries they perform. Ophthalmological surgeries in 2010 had a budget of $ 209,060,000.

 
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