Private health insurance coverage-related lawsuits / Acciones judiciales relacionadas con la cobertura de prestaciones en la salud complementaria / Ações judiciais relacionadas às coberturas assistenciais na saúde suplementar

ABSTRACT Objectives: to analyze lawsuits brought by beneficiaries of health insurance operators. Methods: this was a cross-sectional descriptive study carried out in a large-capacity private health insurance operator using data collected by the company from 2012 to 2015. Results: ninety-six lawsuits were brought by 86 beneficiaries regarding medical procedures (38.5%), treatments (26.1%), examinations (14.6%), medications (9.4%), home care (6.2%), and other types of hospitalization (5.2%). The procedures with the highest number of lawsuits were percutaneous rhizotomy; chemotherapy; treatment-related positron-emission tomography scans; and for medications relative to antineoplastic and Hepatitis C treatment. Conclusions: the lawsuits were filed because of the operators' refusal to comply with items not established in contracts or not regulated and authorized by the Brazilian National Regulatory Agency for Private Health Insurance and Plans, refusals considered unfounded.

RESUMEN Objetivos: analizar las acciones judiciales iniciadas por beneficiarios de planes de salud de prepago. Métodos: estudio descriptivo, transversal, desarrollado en importante operadora de planes de salud de prepago, utilizando datos recopilados por la empresa entre 2015 y 2015. Resultados: fueron impulsadas 96 acciones judiciales por parte de 86 beneficiarios, referentes a procedimientos médicos (38,5%), tratamientos (26,1%), estudios (14,6%), medicación (9,4%), Home Care (6,2%) y 5,2% por otros tipos de internación. La mayoría de acciones por procedimientos correspondió a rizotomía percutánea; en tratamientos, a quimioterapia; en estudios, a tomografía por emisión de positrones; en medicamentos, a antineoplásicos y para tratar la hepatitis C. Conclusiones: motivaron las acciones judiciales interpuestas la negativa de la operadora de planes de salud a cubrir prestaciones no incluidas en el alcance del plan contratado por el beneficiario, así como asuntos no reglados y autorizados por la Agencia Nacional de Salud Complementaria, considerándose, en consecuencia, improcedentes.

RESUMO Objetivos: analisar as ações judiciais demandadas por beneficiários de uma operadora de plano de saúde. Métodos: estudo descritivo de corte transversal desenvolvido em uma operadora de plano privado de saúde de grande porte, utilizando dados compilados pela empresa no período de 2012 a 2015. Resultados: foram movidas 96 ações judiciais por 86 beneficiários, referentes a procedimentos médicos (38,5%), tratamentos (26,1%), exames (14,6%), medicamentos (9,4%), Home Care (6,2%) e 5,2% a outros tipos de internações. O maior número de ações dentre os procedimentos foi rizotomia percutânea; para tratamentos, a quimioterapia; exames solicitados de tomografia por emissão de pósitrons; para medicamentos, os antineoplásicos e para tratamento de Hepatite C. Conclusões: a razão para as demandas judiciais impetradas foi a negativa da operadora em atender os itens não pertencentes ao escopo do que foi contratado pelo beneficiário ou itens não regulamentados e autorizados pela Agência Nacional de Saúde Suplementar, portanto sendo consideradas improcedentes.

Application of preventive medicine resources in the health insurance system / Aplicação de recursos em medicina preventiva no sistema de saúde complementar

ABSTRACT Objective To identify the financial resources and investments provided for preventive medicine programs by health insurance companies of all kinds. Methods Data were collected from 30 large health insurance companies, with over 100 thousand individuals recorded, and registered at the Agência Nacional de Saúde Suplementar. Results It was possible to identify the percentage of participants of the programs in relation to the total number of beneficiaries of the health insurance companies, the prevention and promotion actions held in preventive medicine programs, the inclusion criteria for the programs, as well as the evaluation of human resources and organizational structure of the preventive medicine programs. Conclusion Most of the respondents (46.7%) invested more than US$ 50,000.00 in preventive medicine program, while 26.7% invested more than US$ 500,000.00. The remaining, about 20%, invested less than US$ 50,000.00, and 3.3% did not report the value applied.

RESUMO Objetivo Identificar os recursos financeiros e os investimentos disponibilizados para os programas de medicina preventiva em operadoras de saúde suplementar de todos os tipos. Métodos Foram levantados dados referentes a 30 operadoras de saúde registradas na Agência Nacional de Saúde Suplementar, de grande porte, com registro acima de 100 mil vidas. Resultados Foi possível identificar o porcentual de participantes dos programas em relação ao número total de beneficiários da operadora, as ações de prevenção e promoção realizadas nos programas de medicina preventiva, os critérios de inclusão nos programas, bem como a avaliação dos recursos humanos e da estrutura organizacional dos programas de medicina preventiva pesquisadas. Conclusão A maior parte dos pesquisados (46,7%) investiu mais de US$ 50,000.00 no programa de medicina preventiva, enquanto 26,7% investiram mais de US$ 500,000.00. Os restantes, cerca de 20%, investiram menos de US$ 50,000.00 e 3,3% não informaram o valor aplicado.

¿Cómo afecta el tipo de seguro de salud a la realización del Papanicolaou en Perú? / How does type of health insurance affect receipt of Pap testing in Peru?

OBJETIVO: Describir la asociación entre la realización de la citología del cuello uterino y el tipo de seguro de salud en las mujeres peruanas, y determinar el papel de las variables sociodemográficas y de salud sexual en esta relación. MÉTODOS: Se realizó un estudio transversal que utiliza la información de la Encuesta Demográfica y de Salud Familiar (ENDES), Perú, 2005-2008, correspondiente a una selección de 12 272 mujeres de 30 a 49 años de edad. La variable dependiente fue la realización de alguna prueba de Papanicolaou (PAP) en los últimos 5 años. Las variables independientes principales fueron el tipo de seguro de salud, el nivel educativo, el nivel socioeconómico del hogar, la etnia y el área de residencia. La asociación multivariada fue estimada a través de la razón de prevalencias, utilizando la regresión Poisson con varianza robusta. RESULTADOS: Se encontró que 62,7% de las mujeres sexualmente activas se habían realizado algún PAP en los últimos 5 años. Este porcentaje de participación variaba según el tipo de seguro de salud, donde las mujeres con seguro público tenían 1,27 (intervalo de confianza de 95% [IC95%]: 1,24-1,31) y las que tenían seguro privado 1,52 (IC95%:1,46-1,58) veces mayor probabilidad de haberse realizado un PAP que aquellas sin seguro. Esta asociación era explicada predominantemente por las variables de posición socioeconómica. Asimismo las mujeres que tenían la participación más baja eran las analfabetas o con educación primaria, de nivel socioeconómico bajo, con antecedente de lengua indígena y que vivían en la zonas rurales-siendo esta brecha aún mayor cuando además carecían de seguro de salud, llegando a ser hasta la tercera parte en relación con los grupos sociales más favorecidos. CONCLUSIONES: Se hallaron desigualdades según el tipo de seguro de salud en la realización del PAP, siendo las mujeres sin seguro las que menos lo utilizaron, lo cual supone una barrera para el acceso al cribado de cáncer de cérvix en Perú.

OBJECTIVE: Describe the association between receipt of cervical cytology and type of health insurance in Peruvian women, and determine the role of sociodemographic and sexual health variables in this relationship. METHODS: A cross-sectional study using information on a sample of 12 272 women aged 30 to 49 years from the Demographic and Family Health Survey (ENDES), Peru, 2005-2008. The dependent variable was receipt of at least one Pap smear in the last five years. The primary independent variables were type of health insurance, educational level, household socioeconomic level, ethnicity, and place of residence. Prevalence ratio, obtained from Poisson regression with robust variance, was used to measure multivariate association. RESULTS: Among sexually active women, 62.7% had received at least one Pap test in the last five years. Percentage of women tested varied by type of health insurance. Women with public or private insurance had a greater probability of having received a Pap smear-1.27 (95% CI, 1.24-1.31) and 1.52 (95% CI, 1.46-1.58) times greater, respectively-than uninsured women. This association was primarily explained by socioeconomic status variables. In addition, women who participated the least in screening were characterized by illiteracy or only a primary education, low socioeconomic level, speaking an indigenous language, and living in a rural area. When they also lacked health insurance, the gap widened, rising to as much as one third compared to more advantaged social groups. CONCLUSIONS: Inequalities were found in receipt of Pap testing according to type of health insurance; women without insurance were least likely to be screened, implying existence of a barrier to cervical cancer screening in Peru.

Impact of Health Insurance Type on the Quality of Hemodialysis Services: A Multilevel Analysis / 예방의학회지

OBJECTIVES: This study aims to compare quality indicators for the hemodialysis services between patients with health insurance and those with medical aid. METHODS: This study used data from sampled hospitals that provided a hemodialysis service. A total of 2287 patients were selected, and the information for hemodialysis service has been granted from medical record reviews. A multi-level regression analysis was used to examine the differences in process and outcome indicators for hemodialysis between patients with health insurance and those with medical aid. Process indicators were defined as: frequency of hemodialysis, hemodialysis time, erythropoietin (EPO) use, measurement of hemodialysis dose at least once a month, measurement of phosphate at least once every three months, and measurement of albumin at least once every three months. Outcome indicators were defined as: hemodialysis adequacy, anemia management, blood pressure management, and calcium, phosphate and nutrition management. The total scores for outcome indicators ranged from 0 (worst) to 4 (best). RESULTS: There was a significant difference in the measurement of hemodialysis dose at least once a month between patients with health insurance and those with medical aid (OR 0.66, 95% CI=0.43-0.99). However, frequency of hemodialysis, hemodialysis time, EPO use, measurement of phosphate at least once every three months, measurement of albumin at least once every three months, hemodialysis adequacy management, Hb> or =11 g/dL, blood pressure within the range of 100-140/60-90 mmHg, calcium x phosphate or =4 g/dL were not significantly different between the groups. CONCLUSIONS: There were no significant differences in outcome indicators for hemodialysis between the groups. Further studies are warranted into the mechanism that results in no differences in the outcome indicators for hemodialysis.

Utilização de diretrizes clínicas em cardiologia na saúde suplementar no Brasil / Utilization of clinical guidelines by health plan operators in the Brazilian health system

OBJETIVO: Apresentar resultados da área cardiovascular de um estudo nacional sobre a utilização de diretrizes clínicas na saúde suplementar. MÉTODOS: Estudo transversal, baseado em amostra representativa das 1573 operadoras de planos de saúde do Brasil, estratificada por macrorregião e segmento do mercado, subdividida em estratos certos e amostrados pelo método de Hedlin, com seleção eqüiprovável feita pelo algoritmo de Hájek em cada estrato amostrado, resultando em 90 operadoras entrevistadas com questionário estruturado; estimação pontual de porcentagens, totais e médias através de fatores de expansão, relativas a uma população N=1572. RESULTADOS: Para 61,2 por cento das operadoras a utilização de diretrizes clínicas deve ser conduzida por órgãos reguladores governamentais, com participação de operadoras, prestadores de saúde e associações médicas. Apenas 32,3 por cento das operadoras conduzem a utilização de diretrizes clínicas, variando de 6,5 por cento (filantrópicas) a 38,2 por cento (autogestão). Entre as operadoras que conduzem o uso de diretrizes, a área cardiovascular apresenta uma das maiores utilizações: infarto agudo do miocárdio (87 por cento); insuficiência cardíaca (85 por cento); procedimentos invasivos em cardiologia (81,1 por cento); hipertensão arterial (74,1 por cento); acidente vascular encefálico (72,2 por cento); diabetes (65,4 por cento). As sociedades médicas são a fonte mais comum dessas diretrizes. 64,1 por cento das operadoras monitoram indicadores de processo/resultado dos prestadores, mas apenas 10,5 por cento monitoram o uso de reperfusão coronariana no IAM de forma sistemática. 73,2 por cento promovem campanhas de promoção/prevenção de agravos: hipertensão arterial (97 por cento), diabetes (93,3 por cento), obesidade (70,7 por cento) e tabagismo (60,8 por cento). CONCLUSÃO: Implementação baixa e incipiente de diretrizes, com variação regional e por segmentos do mercado. De uma forma geral, a área cardiovascular...

BACKGROUND: The objective of this study is to present cardiovascular results of a national study about the implementation of clinical guidelines and other instruments and practices for clinical care management among health plan operators in Brasil. METHODS: This was a cross-sectional study based on a representative sample of the 1,573 Brazilian health plan operators, stratified by macro region and market segment. Each stratum was subdivided in take-all and take-some strata by Hedlin's method, with equiprobability selection in each take-some stratum. The resulting sample size was of 90 health plan operators who were interviewed using a structured questionnaire. The study had a descriptive nature and, to obtain estimates for percents and total number of health plan operators relative to a population size of N=1572., sample weights were taken into account. RESULTS: Of the health plan operators, 61.2 percent considered that the implementation of clinical guidelines should be conducted by administrative and regulatory government organizations, involving a partnership with health plan operators, health service providers and medical societies. It was shown that only 32.3 percent of the health plan operators in the country enforce clinical guidelines. With regard to cardiovascular disease, the reported utilization of guidelines was one of the highest among all diseases analyzed. The percentages for acute myocardial infarction (87 percent), congestive heart failure (85 percent) and the use of invasive procedures (81.1 percent) were higher than for arterial hypertension (74.1 percent) and cerebrovascular disease (72.2 percent). CONCLUSION: This study indicated the incipient utilization of clinical guidelines among health plan operators in the Brazilian health system. In general, the cardiovascular area showed one of the highest rates of utilization reported in the study.