Carlos Rus - President, ASPE, Spain

EF: What are the current priorities on your agenda? 

Over recent years, we have outlined a strategic plan to define our focus areas, including our current priorities and a vision for the future of the next decade. This approach is especially crucial in Spain, where executives often find themselves absorbed by urgent, short-term matters. In a healthcare environment characterized by stress, with patients, emergencies and the management of professionals demanding constant attention, it is essential that we can project ourselves forward and anticipate the challenges we will face. 

We began 2024 with a priority objective, which is to place the patient at the center of our activity. We are going to increase interaction with patient associations, listen to their needs and activate our collaboration. In addition to valuing what private healthcare brings them, both in terms of quality of care and access, but also in relation to our social responsibility. 

One of the realities that we must face is the transformation in the insurance industry. With significant demographic changes, we will encounter an increasing population of chronic patients with multiple conditions, which poses challenges for the insurance sector in terms of economic viability. Technology emerges as the answer that can make a system that, at the moment, faces difficulties sustainable. We can foresee with relative certainty how key aspects such as innovation, patient expectations and health insurance will evolve over the next ten years. It is essential that we take advantage of these forecasts to identify opportunities and prevent potential adverse effects. 

For example, in Spain, insurance companies have the ability to cancel patients' policies at will, raising concerns regarding rising costs and health claims. We propose a model that links increases in insurance premiums to the cost of living, rather than loss ratios. It is essential to ensure that insurance companies cannot cancel the policies of those who meet their payment obligations. We are working on preventative measures to avoid possible future scenarios where this practice may become more common. 

At ASPE, we are intensely dedicated to areas such as political defense, institutional and media representation, the generation of studies in collaboration with a university chair and the integration of new professionals. We are proud to be one entity that takes a systematic perspective toward the future. The decisions we make today will have a significant impact on the healthcare sector a decade from now, and we are committed to ensuring our message and actions are powerful and geared toward building a more sustainable and equitable healthcare future. 

EF: Preventive care is a key investment. How is ASPE working to shift the paradigm to a preventative healthcare system approach? 

Today, the reality is that we cannot afford preventive medicine. We have health insurance, but it is not sufficient. The insurance sector is highly concentrated, with five companies having 75% of the market share and the first ten above 85%. None of these offer preventive insurance policies. 

This scenario presents us with a real challenge that we cannot ignore. Preventive medicine can play a very important role, in transforming the way we approach health with a proactive approach to disease prevention. The advancement of technology, such as artificial intelligence, big data analysis and telemedicine, will allow for continuous monitoring and faster, more accurate decision-making in disease prevention. 

Preventive medicine will not only seek to prevent disease but also improve quality of life, reduce the burden on health systems and move towards a more comprehensive and personalized approach to health care. So, it is crucial that we transform health coverage into true medical insurance, differentiating ourselves by the inclusion of preventive and predictive policies. Predictive medicine, in particular, can be of great help in advancing preventive medicine. 

I recognize that in our Latin culture, adopting preventive measures is not easy and that the idea of predictive medicine can generate fear. However, we should see it as a fundamental tool to achieve the desired prevention. For example, if we know that an individual has a high genetic predisposition to lung cancer, adopts habits that induce it, and lives in a stressful environment, it is crucial that he or she undergo a preventive examination in time. 

It is essential to understand that patients in the public sector usually go to hospitals for specific procedures through referral and waiting lists, while private patients demand services that the public system does not provide, such as cosmetic surgeries, ophthalmology and non-urgent medicine. 

In this sense, it would be interesting to promote regular check-ups, as well as genetic, preventive and predictive medicine, since these are essential tools to face current challenges in the field of health. We should, for example, look for ways to reduce the cost of genetic testing, and even consider offering it free of charge. 

EF: What initiatives does ASPE have to encourage private-public collaboration and promote interoperability between the public and private sectors?  

The total interoperability of the country's entire health infrastructure is the only formula that guarantees a real benefit in terms of health care. Therefore, the interoperable digital medical record of health data must incorporate the private health sector and not be limited only to the public circuit, since it would represent a limitation that would harm both patients and health professionals. 

The Spanish model works based on the central government and seventeen autonomous communities; the autonomous communities can decide on health models, leaving us with seventeen models with a common cause. Our battle in interoperability goes from autonomous community to autonomous community, not at the central level. 

Currently, patients cannot manage their medical history or have easy access to their information. They must wait a month for an administrative procedure to authorize it. To achieve interoperability and integration, IDIS has developed a tool that facilitates the flow of information from private to public. 

We are working on convincing autonomous communities to change legal regulations to share public information with private under the patient's authorization, which is now illegal in most regions. The first step is to change and implement the regulations, create a capacity agreement and an agreement with IDIS to share information, and have a tool to share our information.  

EF: You have been ASPE´s president since 2019, just before the pandemic broke out. Could you reflect on navigating through that period? 

I was appointed president in November 2019, just before Covid arrived. During that critical time, we worked 15 hours daily, including weekends, having executive committees three times a week. It was a marathon, but we learned a lot and we were able to establish good institutional relationships.  

Our role was to highlight what the private sector was voluntarily doing and that made that we achieved a better appreciation, including from the citizens' perspective. People warmed to us eliminating differences, no longer applauding the public or the private but rather the professional. 

Of course, we also had tense and complex times; for example, people were dying due to a lack of equipment in Madrid, whereas in Andalusia, there was plenty of equipment, generating tensions at a political level. Although they wanted us to send equipment from Andalusia to Madrid, it was never in writing in case the situation became complex in Andalusia, not to be responsible for taking away equipment from that community. Eventually, we sent 110 pieces of equipment, a great opportunity to prove our value. 

Covid is over, but a second pandemic in Spain is called the Waiting List. In Spain, we currently have more than 800.000 patients on the surgical waiting list and more than 3.5 million waiting for specialist consultation - and it continues to grow. Although this situation, healthcare is still used as a political weapon. Many communities do not dare collaborate with the private sector or don't do it as they should, which becomes a barrier to solving the problem. 

EF: Does ASPE have initiatives to collaborate with the different health providers? 

The dynamics with insurers present notable complexity. On the one hand, they are our main allies, being responsible for 65% of our turnover. However, face-to-face communication is scarce, and the sector is frustrated by the restrictions imposed. 

In this sense, it is essential to deepen the relationships of the healthcare provision sector with insurers and that these relationships be based on transparency and the conviction that we are strategic allies, that we need each other to continue growing but, yes, of sustainable way. 

We have to set common guidelines, protocolizing medical processes in the nomenclature or establishing contractual relationships in writing, with the final objective of providing a higher quality service, and that the collaboration between both parties is absolute, "because we need each other, we coexist and we are interdependent. 

For example, it is necessary to establish an appropriate scale for professionals. When prices are tight, doctors tend to schedule appointments too frequently, which leads to overattend patients. Although companies implement contractual models to mitigate this hyperfrequency, the lack of dialogue prevents them from effectively addressing these problems and satisfying all parties involved. 

It is imperative to establish rules based on mutual trust. For the last decade, we have been engaged in this fight, developing good practice protocols as a form of self-regulation in our sector to prevent such behaviors. However, recent changes in the presidency and the health insurance subcommittee of UNESPA, the insurance employers' association, have caused a paralysis of this initiative. 

It is clear that we have the highest level of professionalism and technology in our sector, but we must also develop the capacity to establish regulations that sanction abusive models. 

EF: Could you share the three pillars that you consider important for the sustainability of the health and hospital system?   

1. Flexibility and adaptability are important for the public and private spheres. The main deficiency of the public sector is the lack of flexibility in the administrative model and the model must change despite resistance.  
2. Adequate human resource planning. To face the current context of the shortage of professionals that we suffer in Spain, we currently need to promote the consolidation of the role of the nursing professional, developing their areas of competence while also reinforcing those of the nursing assistant technicians, for which we believe it is convenient to create a higher degree of Professional Training that allows them to acquire greater functions. An assistant is trained in two years, a nurse in four, and a doctor in ten years; we need solutions to modify these professional skills, which will play a crucial role.  
3. Technology as an ally to achieve sustainability. Technological equipment constantly evolves, which requires agile adaptation, also considering the need to ensure results and avoid duplicating services. For example, in Madrid, we have two machines for proton therapy, and two more will soon be added to the public sphere, which is redundant. 

Likewise, from a medical innovation perspective, more powerful and personalized drugs are increasingly being introduced to meet specific patient needs, which poses a considerable economic challenge and makes it evident that technology must be a fundamental tool in this sense that helps us be more efficient and optimize resources. 

EF: Do you have a final message you would like to share?  

Regardless of the political circumstances, there is no sustainable solution for the future in Spain without the private sector. I believe the private sector has a great future, and the public sector is becoming increasingly complicated. If they are not prepared to reach out to us, we will end up being much more relevant than they are.