Public healthcare attends tourists for free: "They were having a snack by the villa's pool and the visit was neither charged nor registered"

PalmaIn a villa in Andratx, the Balearic public health service went to attend to a tourist, diagnosed him with a kidney stone, gave him medication, and left without charging him a single euro. The visit was also not recorded. It was an Austrian couple without a European Health Insurance Card, and the professionals had to travel to their home to attend to the man. "We found them both having a snack by the pool, a tremendous luxury. We did everything in English. The visit was neither charged nor recorded," explains a nurse with professional experience in different centers in Mallorca.

It is not the only case he remembers. Also in Andratx he attended an Irish woman who was drunk and without any documentation. The situation became complicated to the point that the professionals had to request the intervention of the Police after the patient and the people accompanying her became very aggressive. Nor in this case was the health assistance charged. These are two examples that help to understand the main problem behind the millions of euros that IB-Salut tries to recover from foreign patients: there is a part of the bill that is known and registered, but there is also another part that disappears before reaching the public health accounts. “The figures that IB-Salut provides on billing and debts are the tip of the iceberg, because a lot of what is not registered,” assures this professional.

Official data allows us to put figures on part of this bill. On July 30, IB-Salut had accumulated 2.58 million euros this year pending collection. During the first two months of the high season alone, between May 1 and June 30, public health services attended to 8,611 patients with a European Health Insurance Card, with a billing of 11.1 million euros. To this figure are added 2,851 non-resident international patients, to whom 2.83 million euros more were billed for assistance.

But these figures only reflect the cost that has entered the billing system. What is not identified, not registered, or not billed does not appear in any debt statistics. It is invisible spending for the Administration. And this is where various professionals place a gap that is particularly difficult to quantify. The invoice may be lost due to lack of documentation, ignorance of the procedure, or because, especially during night shifts, healthcare professionals have to assume administrative tasks that do not correspond to them or that they do not know how to perform.

When collection depends on the healthcare professional

One of the most problematic situations occurs in continuous care centers during the night. In certain PACs, like the one in Sóller, from 8 p.m. to 8 a.m. there is no admission staff. There remains a doctor and a nurse, who have to do both care work and administrative procedures. “In the evening, from 8 p.m. onwards, there are two healthcare professionals left and we have to enter data and charge ourselves,” explains a nurse at the center. “We are not administrative staff,” she states. Another professional with experience in Sóller, Andratx, and other centers explains that this situation leaves room for individual decisions: “There are people who are too lazy to do the administrative procedure, or who do not want to do it directly because they consider that it is not their responsibility. Between ‘it’s not my job’, ‘I don’t know how’ and ‘I won’t do it’, we are stuck as we are,” she laments.

The result may be that the patient is attended, but the procedure to recover the expense is not completed. “There are professionals who enter the patients' names but do not charge them and others who do not even register that that person has been to the health center,” he explains. During the day, the admissions staff usually process the payment for foreigners without a European Health Insurance Card, but at night and until 8 a.m. the center becomes a PAC and the staff is reduced to a minimum. “During this time, there are indeed patients who leave without paying for the hour or the staff, but they are the minority,” he points out.

“During this time there are patients who leave without paying for the hour or the staff, but they are the minority,” he points out.

The difficulty is not only that some patients do not want to pay. There are also problems in determining who has to pay and how each case should be processed. One of the main tools is Civitas, the application that allows checking the user's health coverage and administrative situation. But, according to an administrative worker at a center in the Plan, not all professionals have access to it or have the necessary training. In addition, there are patients who arrive without documentation. “Many users present themselves at health centers without the necessary documentation,” she explains. This can make it difficult to know at that moment if they have a European Health Insurance Card, insurance, or if the assistance is billable.

At the Can Picafort PAC, a professional explains that she has encountered users who get angry when asked to identify themselves. In a recent case, a man who needed treatment claimed to have a European Health Insurance Card, but did not show it. When he was told that he had to prove it to avoid paying, "he left because he didn't want to accept it". Cases like this show that the problem is not just recovering an invoice already issued, but ensuring that the assistance is correctly entered into the administrative circuit.

The amount that can be lost depends on the assistance. A visit to the Emergency Room without admission costs 349 euros; hospital admission, 1,092 euros per day, and an ICU stay, 2,094 euros daily. A heart attack can represent between 5,476 and 12,725 euros, while appendicitis can reach 25,062 euros. These are amounts that explain why an efficient billing system can have a considerable impact. But also why assistance that falls outside the administrative circuit is difficult to absorb in an overwhelmed public healthcare system that needs every resource it can get.

To improve healthcare

For the president of the Medical Union Simebal, Miguel Lázaro, recovering this money is especially important in a healthcare system under strong care pressure. “It is a lot of money. Maximum responsibility must be demanded when charging any cost derived from healthcare assistance to visiting tourists,” he argues. Lázaro calls for a “specific billing unit, with trained staff, to be responsible for registering patients and charging for services.” And he places the problem in the context of a healthcare system that needs resources: “These millions that remain to be collected would be very useful for us to recruit doctors, especially during the summer.”

The Balearic Islands receive close to 20 million tourists each year, a figure that is increasing, and some end up going through public healthcare. When applicable, this expense must be recovered from the patient, their insurance, or their country of origin. But the 2.58 million euros pending collection are only what has become visible. Beneath the tip of the iceberg are all the services that do not even get registered or billed. Care that is provided, but not charged for; money that does not reach public healthcare and that, in the end, is ultimately borne by all residents.