at the HAP
The Huisartsen Post (HAP) at St. Maarten Diagnostic Center N.V, a pilot project, saw its first clients on Friday, September 15, 2023. Less than a year later, Social & Health Insurance (SZV) pulled the plug on the HAP.
The HAP center in St. Maarten was intended to provide an essential service—after-hours medical care for non-life-threatening emergencies. The concept is widely used worldwide and helps ease the burden on emergency rooms. However, the results of an audit conducted by SZV on the HAP and its operations, allegedly revealed that the HAP center was being misused and, more significantly, had become a financial drain on SZV.
The secretive report could not be obtained from management of SZV who, on legal advice, declined to comment. Neither could it be obtained from the Mistry of VSA or the Minister of VSA, who referred The Peoples’ Tribune to SZV for answers. Lastly the report was also not provided by management of the HAP itself, in the person of Dr. Danny Dennaoui. However, Dr. Dennaoui did grant The Peoples’ Tribune an interview to address rampant speculation, innuendos and unconfirmed details in the audit report which has not been made public. His interview follows below.
Prompted by inquiries from this media outlet about the report, Minister of VSA Richinel Brug explained that the audit report is not a Ministry of VSA report. This report, he said, was written by a stakeholders committee that was put together by and on request of SZV. This report was submitted on a confidential basis to the Ministry.
During the budget debate in Parliament, Minister of VSA said: “The Simpson Bay clinic informed the Ministry that they offer after-hours services similar to their regular daytime care. This means they are not operating as a true HAP but simply providing after-hours GP (General Practitioner) services, which any registered GP can do.”
The Minister continued: “The clinic did not receive special permission for after-hours care. Instead, in 2023, the then Minister instructed SZV to conduct a pilot program for after-hours urgent GP care at the Simpson Bay clinic. However, the evaluation of this pilot revealed some issues and deviations from the contract terms. The main concern is ensuring that the limited healthcare funds are used efficiently while maintaining quality care. The Ministry is working on properly implementing the HAP model to achieve these goals and provide reliable after-hours urgent GP care.” The Minister did not say when or where a HAP model would be “properly implemented”.
The Purpose of the HAP Center
The idea behind the HAP center was simple: individuals who faced minor medical emergencies outside of regular clinic hours, such as children with fevers or adults with minor injuries, could receive quick treatment without overwhelming hospital emergency rooms. The initiative aimed to provide an efficient and accessible alternative to the hospital while ensuring people received timely care.
The audit conducted by SZV has reportedly exposed troubling practices at the HAP center. Very reliable sources close to the issue pointed out that patients seeking medical attention were reportedly subjected to unnecessary procedures and excessive charges. One of the most concerning issues was the administration of a so-called “vitamin injection,” given to nearly every patient regardless of their actual condition. This injection, it is alleged, is believed to have minimal medical benefit. Patients were also reportedly regularly sent for unnecessary lab tests, further driving up costs.
Additionally, the audit revealed that the center was reportedly not functioning as intended. Instead of serving as an emergency alternative, it became the preferred medical stop for many working individuals who found it more convenient to visit after hours rather than during regular office hours at their assigned general practitioners (GPs). Since SZV pays house doctors based on a set number of patients, regardless of whether those visits actually take place, the shift of patients from house doctors to the HAP center led to double billing. Essentially, SZV was paying for consultations twice, once to the house doctors and again for after-hours services at HAP.
Once the audit results revealed massive costs overrun for SZV, The HAP reportedly was given the opportunity by SZV to address all of the findings and cease with practices outside of its purview and permissions. Reportedly, the HAP continued with the alleged practices until SZV decided enough was enough. It was not a decision taken by government as the initiation of the HAP did not come from the government of St. Maarten.
Financial Drain on SZV
The alleged misuse of the system resulted in skyrocketing healthcare costs. Patients were being asked to return for follow-ups at HAP rather than being referred back to their house doctors, further increasing costs. Tourists were also reportedly being charged exorbitant fees, with reports of individuals paying $100 or more for basic medication like paracetamol.
Another revelation reportedly in the audit report, was the prescription of Ozempic, a diabetes medication, as a weight-loss treatment for individuals who did not have diabetes. This raised ethical and legal concerns about medical malpractice at the facility.
Following the audit and unwillingness of the HAP to stop with certain practices, SZV determined that the financial losses were unsustainable and the situation untenable and moved to terminate its contract with the HAP center. Again, the center was initially given time to rectify the issues, but the abuses allegedly continued. This is a claim that Dr. Dennaoui contradicts in his interview below. In any case, despite political pressures and concerns over public backlash, SZV ultimately shut down the facility.
The Aftermath
This case exposed significant flaws in St. Maarten’s healthcare system, including weak oversight, regulatory loopholes, and a lack of accountability in the medical field. The issue also highlighted the need for reforms in how medical services are billed and how government funds are allocated to healthcare providers. (side-note: more on this aspect to come in a different article). With SZV struggling financially, addressing these inefficiencies is crucial to maintaining a sustainable healthcare system.
SZV reportedly stressed to the government that the closure of the HAP center was a necessary step to prevent further financial exploitation. However, the fundamental issue of after-hours care remains unresolved. Unless the government and medical community can implement a fair and effective alternative, patients may continue to face challenges accessing medical care outside of regular hours. The HAP center was a good idea that went wrong.
Interview with Dr. Danny Dennaoui:
Dr. Danny Dennaoui, head of the HAP’s management, provided insight into the issues raised by the Minister of VSA, the discrepancies highlighted by SZV, and the broader implications for healthcare accessibility in St. Maarten. In this interview, he addresses the concerns, clarifies HAP’s approach to patient care, and discusses the impact of the center’s closure on the community.
1. The Minister of VSA Mr. Brug informed Parliament that the evaluation of HAP’s services “revealed some issues and deviations from the contract terms.” Can you clarify what these issues and deviations were from HAP’s perspective?
The objective of the project was to provide care and attention to all patients who visited the clinic when they needed medical assistance. However, after triage and consultation, some cases were determined to be non-urgent. SZV did not agree with the original objective or approach and insisted that only critical cases be seen and billed. It was repeatedly explained that the urgency of a medical concern is best determined by the patient seeking care, rather than by the insurance company dictating which cases warrant medical attention. As doctors, we take a Hippocratic Oath, to uphold certain ethical standards, including “to help the sick and abstain from all intentional wrong-doing and harm,” this means that we cannot turn patients away, especially if they choose to visit the clinic at 8 PM on a Sunday night due to extreme discomfort from illness or injury. Hence, we are under oath providing the highest quality medical care for our community members.
2. The audit conducted on the HAP center reportedly uncovered financial irregularities. What specific findings emerged, and how did HAP address these discrepancies?
The first and only audit, conducted after six months of HAP, revealed that many of the cases seen at the clinic were not classified as urgent. Additionally, multiple items were billed per visit, leading to higher overall costs. In response, SZV met with SMDC to discuss policy changes. Within the same week, these changes were implemented, resulting in a 60% reduction in patient access to HAP. SZV imposed strict limitations on the number of visits patients could make to the clinic. If a patient exceeded the allowed visits, none of their medical bills would be covered. Furthermore, SZV restricted the number of procedures that could be performed, reducing the range of services available to insured patients.
In contrast, NAGICO-insured and CASH patients received a broader range of services, as SZV dictated the level of care its insured patients could receive. Any additional efforts made for SZV patients required justification before reimbursement was considered.
3. How much did the HAP service cost SZV over the duration of its operation? Which service category accounted for the highest costs?
While SMDC does not disclose protected financial information related to the project, we can confirm that maintaining operations is extremely costly. Staffing a team of nurses, doctors, administrative personnel, and security, along with maintaining medical equipment, requires significant financial resources.
Despite these challenges, SMDC received no financial support from the government or SZV to cover operational costs. The project relied solely on patient visits to break even. However, during the last two months of summer, patient volume was insufficient to sustain the project, resulting in financial losses and ultimately closure.
4. Did SZV express concerns about the sustainability of the HAP service in its current form? If so, did they recommend alternative solutions or specific changes to the service model?
While concerns were raised, no guidelines were provided on how to address them, despite multiple attempts to navigate the appropriate channels and implement solutions. Efforts to engage in discussions were repeatedly met with refusal, leaving no clear path forward.
5. There were reports of patients and SZV being charged repeatedly for services such as injections and lab tests that were deemed unnecessary or redundant. How does HAP respond to these claims, and were such issues highlighted in the audit findings?
Medicine is a vast field, and differential diagnoses always exist. When a patient seeks care at night, presenting with multiple concerning symptoms, severe enough that they did not wait to see their GP/doctor during regular hours, it is only natural that diagnostic tests will be performed. This approach mirrors urgent care rooms, where billing begins the moment a patient enters the Urgent Care Center.
Every service provided in an Urgent Care and/or Hospital is billed separately, for example, an ECG, an injection, or any other procedure. Our model followed the same principle, operating as a business while adhering to standard billing practices. We structured our services based on those typically performed by general practitioners (GPs) during the day and billed accordingly. We also ensured that all services rendered fell within the standard scope of a GP’s practice as was mandated by the audit.
6. The audit allegedly revealed that HAP was administering simple injections (possibly placebo treatments) for a variety of ailments. How does HAP explain this practice, and what protocols were followed in these cases?
A doctor exercises professional judgment in determining the necessary actions to best support and treat patients. Medicine is not solely limited to pharmaceutical interventions; we recognize that natural supplements can also play a crucial role in improving a patient’s condition when deficiencies are present. When patients benefit from such treatments, the positive effects can often be observed in their blood work.
7. Why did the HAP center frequently refer patients for follow-up visits instead of directing them back to their general practitioners (GPs), especially considering that SZV already compensates GPs for patient care?
Patients who visited HAP highlighted a significant issue in the healthcare system, difficulty accessing their general practitioners (GPs). These patients could not simply be referred back to their primary doctors, as their physicians were unavailable at the time they needed care. Additionally, some GPs have long wait times, with appointments scheduled weeks in advance pushing walk-in or referred patients out further. However, certain medical conditions, such as wound care or ongoing evaluations, require continuous monitoring and treatment, making HAP a necessary alternative for timely medical attention.
8. There were allegations of non-emergency treatments being overprescribed, such as the use of Ozempic for weight loss. How does HAP justify such practices and were there any consequences or adjustments made based on the audit findings?
Ozempic is primarily indicated for the treatment of hyperglycemia in diabetics; however, it is also widely used for weight management. It was determined by all parties that when it comes to prescribing Ozempic for weight loss, the situation becomes more complex and requires careful consideration and monitoring, hence HAP stopped these administrations. In other words, after the audit, HAP only administered Ozempic for its primary medical purpose.
9. Regarding the licensing and qualifications of HAP’s managing doctor, how does HAP ensure alignment with the legal and professional requirements for providing General Practitioner-level care? What measures are in place to maintain compliance with medical regulations?
The Department of VSA never objected to the care provided at HAP. Throughout the entirety of its operation, not a single fatality occurred, demonstrating that the doctors, who also serve as GPs during the day, delivered the same high standard of care at night when needed. Additionally, protocols were in place to transfer patients to the ER when necessary.
The HAP saved countless lives and provided critical medical services on holidays, weekends, and even during severe weather conditions. We served the community, and the community responded with overwhelming support, gathering over 3,000 signatures in petitions to reopen. The doctors came together to offer extended hours, ensuring that sick children and the elderly received care when the ER was unable or unwilling to accommodate them.
Despite the undeniable value of our service, there has been reluctance to acknowledge the truth—without SMDC’s HAP, the island is not better off. Over 7,000 patients received care through this initiative, and the vast majority had positive experiences. In contrast, other establishments open during nighttime and weekends have faced significantly more complaints and concerns from the public.
The HAP opened back in November to show our commitment, but we do not hold the contract with SZV anymore, so that patients who are not our patients must pay now as to prior they were covered by SZV. We think it’s wrong that SZV does not give them coverage, but the hospital does. Otherwise, our patient can access it for free.
Source: The Peoples Tribune https://www.thepeoplestribunesxm.com
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