However, that is not the central point of this feature article.
Beyond the surface-level frustrations, lies a deeper issue, one rooted in outdated policies, stagnant medical tariffs, and a critical lack of cooperation between the Ministry of Public Health, Social Development and Labor (VSA) and the Social & Health Insurances (SZV). These issues have left St. Maarten’s general practitioners (GPs) undercompensated (and some say overworked) in a system that has failed to evolve alongside the island’s healthcare needs.
In this feature, The People’s Tribune speaks with Dr. Pedro Arrindell, one of the island’s most experienced and outspoken medical professionals, to unpack the pressing issues facing GPs today and provide a reality check on the challenges faced by local doctors and the critical changes needed to ensure sustainable healthcare services for St. Maarten. At the heart of this issue lies the failure of the Ministry of Public Health, Social Development and Labor (VSA) and medical insurer Social & Health Insurances (SZV) to work together to resolve long-standing concerns.
The Lack of After-Hours Compensation
There was once a times when home-visits after hours to patients was common-place. Today Dr. Arrindell is probably the only doctor that still does this on a regular basis. One major issue that has plagued St. Maarten’s GPs for years is the lack of structured and fair compensation for after-hours care. While doctors are contractually obligated to provide after-hours services, they are not supposed to without an agreed out-of-hours fee for services. According to Dr. Arrindell this has never been properly sorted out.”
Last year, an attempt was made to address this issue with the introduction of a pilot project for a Huisartsen Post (HAP), an after-hours GP service. However, this initiative was discontinued due to suspected irregularities. A new version of the HAP is currently in development with stricter guidelines and oversight. However, legal uncertainties remain an obstacle to its full implementation. “The Minister of VSA is still reviewing legal issues before the HAP can be relaunched.”
Outdated Tariffs and Unfair Compensation
St. Maarten’s GPs are still being compensated under outdated medical fees from the former Netherlands Antilles. These fees have not been adjusted to reflect inflation, making it increasingly difficult for doctors to maintain their practices. The only exception is the agreement between the Windward Islands Medical Association (WIMA) and private insurers, which allows for annual inflation-based adjustments. “Obviously, it is very unfair to pay doctors outdated non-adjusted to inflation fees to take
care of patients which is a very responsible assignment,” Dr. Arrindell said.
Despite these inadequate tariffs, GPs are still expected to provide 24/7 care year-round, as per regulations inherited from the Netherlands Antilles. “The SZV regulations, inherited from the Netherlands Antilles, still claim that GPs must provide 24/7 service year-round without special compensation for after-hours work, except for home visits. This is impractical and irresponsible.”
This problem, he said, has to be jointly solved with WIMA, SZV and VSA, “but unfortunately there is no movement nor appetite predominantly from SZV and VSA to resolve this issue in the interest of all concerned parties.”
Doctor’s compensation is different. While private insurance patients (OZR) are billed per consultation, SZV patients are handled differently. “For SZV patients there is a fixed fee per registered patient, per quarter (every 3 months), regardless if the patient requests service zero or two hundred times. Small medical/surgical procedures and home visits are billable,” Dr. Arrindell explained. OZR (PPK & GAR Patients) are billed per consultation and home visit.”
Despite this, night shift fees under the HAP system remain unresolved, leaving doctors uncompensated for essential after-hours services.
The Government’s Resistance to Change
The reluctance of the government and SZV to update tariffs has sparked frustration within the medical community. Dr. Arrindell challenges government officials to consider whether they would accept similar working conditions. “Would these same government officials be happy to work for 30-40-year-old salaries with no inflation adjustments, despite rising living costs?”
The lack of collaboration between VSA, SZV, and WIMA is another major roadblock in achieving necessary reforms. The government appears unwilling to recognize the challenges that doctors face.
SZV is currently conducting a medical tariff review, but according to Dr. Arrindell, the way it is being conducted is “mediocre and inadequate as it (SZV) is unwilling to sit with VSA and jointly establish a level of health care that it wants to apply to the new fees/tariffs. It is unintelligent to speak about tariffs adjustment before clearly defining what level of
service and care those tariffs need to be applied to,” he said.
The Need for a Clear Healthcare Standard
“A clear level of health care” refers to a well-defined and standardized quality of medical services that ensures consistency, accessibility, and effectiveness in patient treatment. It involves setting benchmarks for medical practices, patient care protocols, and healthcare infrastructure to guarantee that all individuals receive appropriate, timely, and high-quality medical attention. This includes clear guidelines on service availability, professional standards for healthcare providers, and measurable outcomes for patient well-being.
Dr. Arrindell emphasizes the importance of defining a clear level of healthcare for St. Maarten. He outlines some key elements that should be included:
“Having a clinic practice nurse for screening & special organized controls/reviews to monitor possible long-term complications for Diabetes & Hypertension. The practice nurse will also have a vital role to play in early detection of non-communicable diseases (lifestyle diseases) and to educate the patients about the required lifestyle changes to mitigate the complications from such diseases,” he said.
He also called for regular set schedules to visit the chronically ill, bedridden, and immobile patients at home instead of just visiting when the family calls for a particular problem, and regular set schedules to visit terminally ill patients at home who decline hospice care.
Another example is treating Mild Asthma Exacerbation patients at the GP’s practice whereby IV or IM corticosteroids and nebulizing can be administered instead of sending each and every Asthma Exacerbation to the ER because the GP Practice does not have the resources nor a practice nurse to assist with such semi-emergency GP cases.
The challenges preventing SZV and VSA from collaborating to establish a standardized healthcare system remain unclear. In fact, Dr. Arrindell said “I have no idea what is preventing SZV & VSA from working together to accomplish this objective.” However, to ensure that tariff adjustments lead to tangible improvements in patient care, he suggested that VSA or SZV could implement measures such as requiring general practitioners (GPs) to submit a two- to three-year audit of their medical services. This would provide oversight and accountability, ensuring that any tariff adjustments directly benefit patient care and overall healthcare quality.
Balancing fair tariffs for medical providers while keeping healthcare affordable for the public is a key concern, or at least it should be for SZV. Dr. Arrindell explained that a significant amount of money is spent on high consultancy fees, often without tangible improvements in healthcare quality. Redirecting these funds toward healthcare providers’ services could enhance patient care and ensure a more effective allocation of resources within the healthcare system.
The Bigger Picture: Mismanagement of Healthcare Funds
Dr. Arrindell points out that much of the financial strain in the healthcare system comes not from GP compensation but from unnecessary expenditures by SZV. He highlights excessive spending on overseas referrals, where patients are sent abroad for extended periods with little justification.
“Most of the unnecessary and irresponsible spending in healthcare can be found in the second line Healthcare (hospital healthcare) rather than the first line Healthcare (GP clinics) and all too often frequent unnecessary follow-up referrals to overseas medical specialists and unexplained long-term overseas stays of medical referrals abroad where patients stay too often up to 6 and 7 months abroad just in the hotel doing nothing to see a medical specialist every 2 to 3 weeks. This is a real waste of the SZV premiums.”
He suggests that rather than focusing solely on tariff adjustments, an independent audit of SZV should be conducted to determine whether healthcare funds are being properly managed.
“In other words, the focus should not be on tariffs adjustment but SZV should be audited by an independent entity to ascertain if the Healthcare Funds are properly managed and to obtain directions on how the SZV should stop wasteful and irresponsible spending of public funds.”
That question, he said, should be posed to both SZV & VSA. “Over the last few years, it is becoming more apparent that SZV is meddling in regulatory issues for GP’s that fall under the jurisdiction of VSA & the Inspectorate Of Health Care. I have no idea why SZV is getting involved in such regulatory issues that it actually has no authority over,” Dr. Arrindell said.
The Way Forward
To resolve these longstanding issues, VSA and SZV must come together to develop a sustainable and fair healthcare structure. This includes adjusting tariffs to reflect inflation, implementing structured after-hours care, and ensuring proper financial management of healthcare funds. Without these crucial changes, the quality and accessibility of medical care in St. Maarten will continue to decline.
Dr. Arrindell did re-assure however, that he is confident in the care being provided. “Even though the medical tariffs have too long been neglected and not adequately adjusted to yearly inflation for the last 25 plus years, GP’s made an oath to practice medicine to a standard in the best interest of patients, and I am confident that the majority of GP’s do so regardless to the fact that they are deprived from respectable medical tariffs for the very responsible assignment of taking care of the health of patients. So, in other words, despite the fact that there are deficient resources in some cases to manage a patient in the best manner the GP wishes, the best possible care is at all time guaranteed.”
And as for regulating clinic opening hours et al, that is the task of VSA, SZV and the Inspectorate of Health. It should ne noted that the Minister of VSA was approached with questions about working hours and tariffs, to which his cabinet responded that these are issues that Ministry is looking into.
Additionally, the Minister of VSA agrees that some sort of a HAP/after hours care concept should be regulated (and also properly regulated) on St. Maarten. according to the Minister’s cabinet, The Ministry is awaiting a report that is set to come out in the second quarter of 2025 on possible ways to properly implement a HAP/after hours care concept. Upon learning of the timeframe for this report, the Minister has requested the Ministry to urge the committee to expedite this report.
Source: The Peoples Tribune https://www.thepeoplestribunesxm.com
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