Santo Domingo.- From 2023the expenses of Subsidized regime of the National Health Insurance (SENASA), They exceed income annual, what can generate operational deficitsaccording to data from the Superintendence of Health and Occupational Risks (SISALRIL).
Financial deterioration occurs in parallel with complaints of generalized fraud in the health system, although it should be noted that the first time the expenses in medical care were exceeded was in 2019 when RD $ 9,634,019,245.50 that entered, were spent RD $ 9,765,212,871.97.
However, until 2022, the expenses, that is, those resources used by the Health Risk Administrators (ARS) to cover the benefits of health services to the affiliates, were relatively controlled with respect to the income, this is the total of resources that an ARS receives for monthly or per capita premiums.
In detail, for 2023 the Income reached RD $ 17,984,572,516 and the bills They exceeded the RD $ 19,895 millionfor a sinisterity of 108%; While for 2024 They entered RD $ 17,962,438,467 And they spent RD $ 9,895,840,698, with a accident rate of 110.76%.
Until May 2025, the data that is preliminary waiting for audit, indicates that the accidents has exceeded 130%which implies that For each RD $ 100 admitted, RD $ 133 are spent in health benefits.
In total, until the aforementioned date, RD $ 2,961,400,455 had entered, but those spent on attention to state insurance members for the most vulnerable exceeded RD $ 3,940,712,719.
Sinisterity greater than 100% can lead to sustainability problems
This situation is worrying if it is taken into consideration that the accidents greater than 100% indicate that the Health expenses are unsustainable without subsidies additional or corrective measures, in addition, that you can compromise payments to providers, purchase of medicines, medical services and affect the continuity of the system.
He Abrupt increase in spending In 2023-2025 it coincides with the complaints of impersonation of identities, fictional medical procedures, invoiced and not delivered medications, which were practices detected to the detriment of the health system, in addition to that two million members were integrated into the subsidized system.
SENASA fraud reveals a broad problem: family health insurance, victim of the crisis
What until a few weeks ago was presented as an isolated scandal of financial irregularities in the Senasa, has begun to show a greater dimension: a structured fraud that affects not only the state insurance, but also the entire family health insurance system (SFS).
And it was initially denounced as a case of internal corruption in Senasa, but now it is emerging as a more complex scheme, which includes providers, pharmacies and health personnel who take advantage of failures in the system controls to fissure the SFS, which also affects private health risk administrators (ARS).
It is also estimated that the false authorizations that, according to the document delivered to the Attorney General’s Office by the Republic Superintendent of the Sisalril, Miguel Ceara Hatton and the current one Senasa director, Edward Guzmán, They amount to an amount of 40 million pesos, were carried out through a parallel call center in the supposedly collaborators of the state body.
For all the above, Senasa initiated a tender for 50 million pesos for the hiring of a private firm that performs an audit from 2018 to 2024, to clarify the situation.
Even in the midst of the investigation, Senasa published yesterday a tender of 198 million pesos in the Purchasing and Public Hiring Portal A call to hire a technological platform aimed at managing the authorizations of medications of its affiliates
Contrast to the contributory regime
He Tax regime of the SFS has shown a more stable management in terms of accidents, compared to the Subsidized regime. However, public Ars are operating to the limit or in deficit.
Until May of this year, health income in the public Ars of this regime, which includes Senasa and Ars reserves, reached the RD $ 6,128,130,345.95 and the spent exceeded RD $ 6,270,930,968,30, for a 102%accident, while last year it was 100%.
In the case of private Ars, these have received RD $ 9,368,710,907.23 in contributions this year, according to preliminary data, and have used some medical services for some RD $ 7,849,175,331.76, for 83.78% of accidents.
The role of medical audits
As Control measurement, The Ars have strengthened their systems of internal and external auditimplementing mechanisms such as prescription verification, post-service of medical claims.
For example, for the authorization of interventions such as surgeries, Ars requires studies that demonstrate the relevance of the procedure with a tomography, if necessary.
