Inclusion of molecular monitoring (BCR-ABL1) in the treatment of chronic myeloid leukemia in the Brazilian Public Health System (SUS): an urgent need for treatment management

ABSTRACT Introduction: Chronic Myeloid Leukemia (CML) is a myeloproliferative disease that affects mainly adults between 50 and 55 years. In Brazil, information from the Sistema Único de Saúde (SUS) Outpatient Information System indicates that 12,531 patients had the Autorização de Procedimento Ambulatorial (APAC) approved for the CML treatment in 2017. Disease monitoring through molecular response evaluation is critical to the care of CML patients. The quantitative PCR test (real-time polymerase chain reaction) provides adequate evaluation parameters that allow the health professional to intervene at the right moments in order to reduce the chance of progression of the disease, providing the best outcome to the patient, including the possibility of treatment discontinuation for eligible patients. Although the test is included in the Clinical Protocol and Therapeutic Guidelines (PCDT) of CML, it is not possible to monitor the molecular response within SUS since there is no reimbursement for this test. Objective: Obtain expert recommendations on the importance, financing, and reimbursement of molecular monitoring in SUS. Methods: Six CML experts with different perspectives participated in the panel. The discussion was based in the main publications about the quantitative PCR test in CML monitoring. Results: Experts' recommendations: Molecular monitoring should be part of the integral treatment of patients with CML to reduce the chances of disease progression and costs to the health system; The government should put into practice what is provided in the PCDT of Chronic Myeloid Leukemia in Brazil: performing the monitoring of the molecular response via quantitative PCR; The government should create a code with adequate nomenclature and reimbursement value in SIGTAP, so that the test is carried out and covered by the public health network, as it is contained in the PCDT of the disease and the existing APAC does not cover the operational costs for its performance; Patients with chronic phase CML should perform a quantitative PCR every 3 months and, after reaching the MMR, should perform the examination every 6 months, as recommended by international guidelines; Patients should be monitored in reference laboratories that are standardized according to the international scale; The laboratories that are within the reference public centers could absorb all the test demand in Brazil, and other centers could be qualified through an ABHH accreditation; Adequate molecular monitoring may allow some patients to stop taking drugs and selffinancing the molecular test for all SUS patients Conclusion: A solution for the molecular test (BCR-ABL1) funding is urgent to ensure the monitoring of CML patients in SUS. The savings that might be generated with patients that stop taking the medication when adequately monitored may finance the test.

Lista de pacientes: reflexões para a prática da medicina de família e comunidade / List of patients: reflections for the practice of family and community medicine / Lista de pacientes: reflexiones para la práctica de la medicina familiar y comunitaria

Este artículo analiza el tema de la lista de pacientes como modelo para vincular a la población con los equipos de Atención Primaria de Salud (APS). Objetivo: destacar las características de la lista de pacientes como modelo de pago. Método: ensayo teórico sobre modelos de pago que analiza el piloto de lista de pacientes de la Secretaría Municipal de- Salud (SMS) de Florianópolis. Para fundamentar los principios de la lista de pacientes, su aplicación se presenta en dos contextos diferentes: (a) en el sistema de salud cerrado, como en las Organizaciones de Mantenimiento de la Salud (HMO) en los Estados Unidos; y (b) en el sistema de salud universal, utilizando el sistema de salud británico como modelo. Discusión: el proyecto piloto de lista de pacientes de la SMS de Florianópolis enfrenta dos problemas estructurales: (a) el sistema de salud universal que caracteriza a la APS brasileña; y (b) el modelo de pago de salarios. Estos dos componentes plantean el desafío de establecer un límite real para las listas de pacientes. Sin límite en el número de pacientes, no es posible ajustar la carga de trabajo de los profesionales de la salud. Adicionalmente, una lista de pacientes basada en el uso repetido y el atendimiento de casos de agudeza fuera de la lista tiende a incrementar la carga de trabajo de los profesionales con el tiempo. No obstante, la lista de pacientes propuesta proporciona una mayor visibilidad de la carga de trabajo facilitando tanto la gestión como el seguimiento de la presión asistencial y la redistribución interna de los pacientes entre los equipos de salud de la APS. También permite justificar la ampliación de los equipos de la Estrategia Salud de Familia (ESF) según datos más fiables sobre la realidad de los servicios e implementar programas de mejora de la calidad. Conclusión: la implementación de la modalidad de vinculación flexible en Florianópolis no tiene impactos positivos directos en la carga de trabajo de los equipos de salud, pero quizás sí de manera indirecta a través de la gestión inteligente de su sistema de APS.

This article discusses the theme of patient list as a model for registering the population to the Primary Health Care (PHC) teams. Objective: to highlight the characteristics of patient list as a payment model. Method: theoretical essay on payment models that analyses the pilot of patient list of the Municipal Health Secretariat (MHS) of Florianopolis. To support the principles of the patient list, its application is presented in two different contexts: (a) in closed health systems, as in the Health Maintenance Organizations (HMO) in the United States; and (b) in universal health systems, using the British health system as a model. Discussion: the Florianopolis MHS patient list pilot-project faces two structural problems: (a) the universal health system that characterises Brazilian PHC; and (b) the salary payment model. These two components pose the challenge of establishing a real cap for patient lists. Without a limit on the number of patients, it is not possible to adjust health professionals' workload. Additionally, a list of patients based on repeated use and on the care of out-of-list acute cases tend to increase the workload of professionals over time. Nonetheless, the proposed list of patients provides greater visibility of the workload facilitating both management and monitoring of care pressure and the internal redistribution of patients among the PHC health teams. It also makes it possible to justify the expansion of Family Health Strategy (FHS) teams according to more reliable data on the reality of services and to implement quality improvement programmes. Conclusion: the implementation of the flexible registering modality in Florianopolis does not have direct positive impacts on the workload of health teams, but perhaps it does indirectly through intelligent management of its PHC system.

Este artigo discute o tema da lista de pacientes como modelo de vinculação da população às equipes de Atenção Primária à Saúde (APS). Objetivo: evidenciar as características da lista de pacientes enquanto modelo de pagamento. Método: ensaio teórico sobre modelos de pagamento que analisa o piloto de lista de pacientes da Secretaria Municipal de Saúde (SMS) de Florianópolis-SC. Para fundamentar os princípios da lista de pacientes apresenta-se sua aplicação em dois contextos diferentes: (a) em sistemas fechados de saúde, como nas Health Maintenance Organizations (HMO) nos Estados Unidos; e (b) em sistemas universais de saúde, utilizando o sistema de saúde britânico como modelo. Discussão: o projeto piloto de lista de pacientes da SMS/Florianópolis enfrenta dois problemas estruturais: (a) o sistema de saúde universal que caracteriza a APS brasileira; e (b) o modelo de pagamento salarial. Esses dois componentes impõem o desafio de se estabelecer um teto real para as listas de pacientes. Sem um limite no número de pacientes não é possível adequar a carga de trabalho dos profissionais de saúde. Adicionalmente, uma lista de pacientes construída com base na utilização repetida e no atendimento de casos agudos não fidelizados tende a aumentar a carga de trabalho dos profissionais com o passar do tempo. Entretanto, a proposta da lista de pacientes confere maior visibilidade da carga de trabalho para a gestão, facilitando o monitoramento da pressão assistencial e a redistribuição interna dos usuários entre as equipes de saúde da APS. Permite também justificar a expansão das equipes de ESF de acordo com dados mais fidedignos da realidade dos serviços e implementar programas de melhoria de qualidade. Conclusão: a implantação da modalidade de vinculação flexível em Florianópolis não traz impactos positivos diretos na carga de trabalho das equipes, mas talvez de forma indireta por meio de uma gestão inteligente da rede da APS.

Critérios de definição de preços de medicamentos no Brasil e em países selecionados: uma revisão comparada / Criteria for setting drug prices in Brazil and selected countries: a comparative review

Objetivos: Comparar os critérios de formação de preços de medicamentos no Brasil e em países selecionados, analisar o mecanismo de formação de preços de medicamentos no Brasil e analisar o mecanismo de formação de preços de medicamentos em países selecionados. Métodos: Foi realizada uma revisão narrativa da literatura por meio do levantamento de informações em bases de dados, em sites das agências nacionais e organismos internacionais e em literatura "cinzenta", a respeito dos sistemas de saúde e mecanismos de formação de preços de medicamentos no Brasil e nos países selecionados (Austrália, Canadá, Espanha, Estados Unidos, França, Grécia, Itália, Nova Zelândia e Portugal). Resultados: A maioria dos países pesquisados utiliza o referenciamento externo e interno de preços, realiza ajustes e correções de preços ao longo do tempo e faz estudos de avaliação econômica. O valor da terapia ou seu benefício para o paciente ou sistema de saúde é um fator importante tanto na determinação do preço como da incorporação no sistema de saúde. Conclusão: Este trabalho permitiu identificar as semelhanças entre as práticas recomendadas e implementadas internacionalmente e as realizadas no Brasil, bem como os problemas relacionados à definição de preços das novas terapias, além das lacunas no modelo regulatório atual

Objectives: To compare the criteria for setting prices of medicines in Brazil and in selected countries, to analyze the mechanism for setting prices of medicines in Brazil and to analyze the mechanism for setting prices of medicines in selected countries. Methods: A narrative review of the literature was carried out by collecting information in databases, on websites of national agencies and international organizations and in "gray" literature, regarding health systems and price formation mechanisms of medicines in Brazil and selected countries (Australia, Canada, Spain, United States, France, Greece, Italy, New Zealand and Portugal). Results: Most of the countries surveyed use external and internal price referencing, make price adjustments and corrections over time and carry out economic evaluation studies. The value of therapy or its benefit to the patient or health care system is an important factor in both pricing and incorporation into the health care system. Conclusion: This work allowed identify the similarities between the practices recommended and implemented internationally and those carried out in Brazil, as well as the problems related to the pricing of new therapies, in addition to the gaps in the current regulatory model

Rationalizing health personnel financing schemes for evidence-informed policy reforms: Policy analysis

Background@#The Universal Health Care Law seeks to optimize financing of personnel costs without compromising quality and equitable health care among the health care facilities. This position statement aimed to identify strategies and policy recommendations for the cost-effective financing of health personnel in public healthcare facilities. @*Methods@#A systematic review of literature was done to generate policy brief and key points for roundtable discussion in collaboration with the Department of Health (DOH). The discussion was guided by the three health financing options of DOH: (a) retain Personnel Services (PS) as DOH budget but shift Maintenance and Other Operating Expenses (MOOE) to PhilHealth; (b) shift PS and MOOE to PhilHealth, and (c) rationalize part-time status in government hospitals. @*Results@#The pros and cons of financing options were cross-examined. In Option 1, physicians in government hospitals would receive fixed salaries from DOH / Local Government Units. In Option 2, there would be a monopsony between PhilHealth and provincial power. Payment will be performance-driven, and balance billing will be eliminated. Option 3 would be a set up of retaining part-time positions for physicians. @*Conclusion and Recommendation@#Participants deduced that for Option 1, provision of salary augmentation sources and ensuring adequate plantilla items and level of remuneration in government hospitals should be considered, in order to sufficiently compete with physicians’ income from private practice. For Option 2, the PhilHealth reimbursement system should ensure timely reimbursement so as not to subject care providers to financial instabilities. For Option 3, rationalizing part-time status should be flexible and can be applied regardless of how physicians are paid, as this would incentivize caregivers to work harder and smarter.

A saúde no STF: o ressarcimento interfederativo à luz do Recurso Extraordinário nº 855178 / The right to health on Brazil's Supreme Court: federation entities reimbursement in light of RE nº 855.178

Objetivo: fazer uma análise crítica sobre a tese da responsabilidade solidária pelo fornecimento de medicamentos, fixada pelo Supremo Tribunal Federal com repercussão geral, no Recurso Extraordinário nº 855.178/SE, ao interpretar a competência administrativa comum da União, Estados e Municípios prevista na Constituição Federal relativamente à saúde, de maneira a chamar atenção para a necessidade de se regulamentar os mecanismos de ressarcimento intergovernamental, com vistas a restabelecer o equilíbrio no pacto federativo. Metodologia: pesquisa teórica e documental sobre o ressarcimento interfederativo de ações e prestações de saúde, tendo como norte o caso que ensejou na fixação da tese. A revisão documental foi o procedimento técnico adotado para fazer a observação indireta do objeto pesquisado, por meio de documentos oficiais, adotando-se como fonte secundária a proposição de Súmula Vinculante nº 4 e o Projeto de Lei nº 4.869/2016, disponíveis em sítios oficiais do governo brasileiro. Resultados: a sistemática fixada pelo SupremoTribunal Federal privilegia o acesso à justiça, de maneira a tornar mais célere a concessão judicial de medicamentos e, em razão disso, tende a fomentar a judicialização da saúde. Conclusões: vislumbra-se o descumprimento da segunda parte da tese, referente ao ressarcimento interferativo, haja vista a complexidade e fragilidade da sistemática atual de reembolso intergovernamental. (AU).

Objective: to criticaly analyze the joint liability of federal, state and municipal governments regarding medication supply, stated by Brazil's Supreme Court with general repercussion on the RE 855.178/SE, when construing on the commom competence established in the Federal Constitution, in order to draw attention to the need to regulate the reimbursement mechanisms of federation entities so the balance of the federative pact is restored. Methodology: theoretical and documentary research on the federation entities reimbursement mechanisms regarding the right to health, focusing mainly on the case that has led to the judicial decision in question. The documentary revision was the technical procedure adopted in order to proceed to the indirect observation through official documents, using as sources of secondary data the proposition of Súmula Vinculante nº 4 e the bill nº 4.869/2016, available on Brazilian government's official websites. Results: the reimbursement mechanism stated by Brazil's Supreme Court privileges the access to justice by making judicial granting of medication a faster mechanism and, because of that, it tends to increase judicialization of the right to health. Conclusions: it is foreseen the failing to comply with the second part of the established method, regarding the reimbursement of federation entities, due to the intricacy and weakness of the current reimbursement system. (AU).

Objetivo: hacer un análisis crítico de la tesis de responsabilidad solidaria por el fornecimiento de medicamentos, establecida con repercusión general por el STF, en el RE 855.178/SE, cuando interpreta la competencia administrativa común de la Unión, de los estados y de los municipios, prevista por la Constitución Federal en relación a la salud, de manera a llamar la atención para la necesidad de reglamentarse los mecanismos intergubernamentales de resarcimiento, restableciéndose el equilibrio en el pacto federativo. Metodología: investigación teórica y documental acerca del resarcimiento interfederativo en las acciones y prestaciones de salud, teniendo como Norte el caso que ha conducido a la fijación de la tesis. La revisión documental fue el procedimiento técnico adoptado para proceder a la observación indirecta del objeto investigado, por intermedio de documentos oficiales, habiéndose adoptado como fuente secundaria la propuesta de Súmula Vinculante nº 4 y el Proyecto de Ley 4.869/2016, disponibles en los sitios internet oficiales del gobierno brasileño. Resultados: la sistemática fijada por el STF privilegia el acceso a la justicia, tornando más célere la concesión judicial de medicamentos y, por ello, puede fomentar la judicialización de la salud. Conclusiones: se entiende que no se va a sostener la segunda parte de la tesis, referente al resarcimiento interfederativo, debido a la complejidad y a la fragilidad del actual sistema de resarcimiento intergubernamental. (AU).

Avaliação dos custos diretos com terapia nutricional enteral em um hospital público / Assessment of direct costs with enteral nutritional therapy in a public hospital

Introdução: A desnutrição representa um alto custo hospitalar, decorrente de gastos com medi� camentos, exames e terapia nutricional em maior tempo de internação. Nos hospitais públicos, o Sistema Único de Saúde (SUS) repassa um valor diário por paciente para subsidiar os custos com nutrição enteral (NE). O objetivo do trabalho foi descrever os custos diretos com NE em pacientes hospitalizados e avaliar o percentual desses custos em relação ao repasse do SUS. Método: Estudo transversal e descritivo desenvolvido no Setor de Terapia Nutricional de um hospital público. Os custos diretos foram quantificados de acordo com consumo e custo diário de fórmulas enterais, frascos e equipos, número de pacientes por dia em uso de nutrição enteral (NE): por sonda e por suplementação nutricional oral (SNO). Os valores obtidos foram utilizados para avaliar o percentual de cobertura do valor padrão repassado pelo SUS. Resultados: No período avaliado, foram quantificadas 2066 solicitações de NE para pacientes (69,4% com NE por sonda e 30,6% com SNO). O custo médio diário por paciente em uso de NE por sonda foi de R$ 23,89 (60,0% referente à fórmula, 30,2% ao equipo, 7,7% ao frasco e 2,1% ao módulo proteico) e em uso de SNO foi de R$ 6,17 (95,7% referente à fórmula, 3,3% do frasco e 1,0% do módulo proteico). Isso representou uma cobertura do valor repassado pelo SUS de, respectivamente, 79,6% e 20,2%. Na NE por sonda, os custos estimados diários com fórmulas foram: semielementares (R$ 22,65), especializadas (R$ 19,58), hipercalórica/hiperproteica (R$ 13,13) e normocalórica/hiperproteica (R$ 10,26). Na SNO, foram de hipercalóricos/hiperproteicos (R$ 6,12), semielementares (R$ 5,80), especializados (R$ 5,43) e normocalóricos/hiperproteicos (R$ 3,51). Conclusões: Observa-se no estudo que o valor repassado pelo SUS com terapia nutricional enteral provavelmente se mostra insuficiente, principalmente para cobrir os custos com NE por sonda.

Hospitalization costs of severe bacterial pneumonia in children: comparative analysis considering different costing methods / Custos hospitalares de pneumonia bacteriana grave em crianças: análise comparativa por diferentes métodos de custeio

ABSTRACT Objective To determine and compare hospitalization costs of bacterial community-acquired pneumonia cases via different costing methods under the Brazilian Public Unified Health System perspective. Methods Cost-of-illness study based on primary data collected from a sample of 59 children aged between 28 days and 35 months and hospitalized due to bacterial pneumonia. Direct medical and non-medical costs were considered and three costing methods employed: micro-costing based on medical record review, micro-costing based on therapeutic guidelines and gross-costing based on the Brazilian Public Unified Health System reimbursement rates. Costs estimates obtained via different methods were compared using the Friedman test. Results Cost estimates of inpatient cases of severe pneumonia amounted to R$ 780,70/$Int. 858.7 (medical record review), R$ 641,90/$Int. 706.90 (therapeutic guidelines) and R$ 594,80/$Int. 654.28 (Brazilian Public Unified Health System reimbursement rates). Costs estimated via micro-costing (medical record review or therapeutic guidelines) did not differ significantly (p=0.405), while estimates based on reimbursement rates were significantly lower compared to estimates based on therapeutic guidelines (p<0.001) or record review (p=0.006). Conclusion Brazilian Public Unified Health System costs estimated via different costing methods differ significantly, with gross-costing yielding lower cost estimates. Given costs estimated by different micro-costing methods are similar and costing methods based on therapeutic guidelines are easier to apply and less expensive, this method may be a valuable alternative for estimation of hospitalization costs of bacterial community-acquired pneumonia in children.

RESUMO Objetivo Determinar e comparar custos hospitalares no tratamento da pneumonia bacteriana adquirida na comunidade por diferentes metodologias de custeio, na perspectiva do Sistema Único de Saúde. Métodos Estudo de custo, com coleta de dados primários de uma amostra de 59 crianças com 28 dias a 35 meses de idade hospitalizadas por pneumonia bacteriana. Foram considerados custos diretos médicos e não médicos. Três metodologias de custeio foram utilizadas: microcusteio por revisão de prontuários, microcusteio considerando diretriz terapêutica e macrocusteio por ressarcimento do Sistema Único de Saúde. Os custos estimados pelas diferentes metodologias foram comparados utilizando o teste de Friedman. Resultados Os custos hospitalares de crianças com pneumonia grave foram R$ 780,70 ($Int. 858.7) por revisão de prontuários, R$ 641,90 ($Int. 706.90) por diretriz terapêutica e R$ 594,80 ($Int. 654.28) por ressarcimento do Sistema Único de Saúde, respectivamente. A utilização de metodologias de microcusteio (revisão de prontuários e diretriz) resultou em estimativas de custos equivalentes (p=0,405), enquanto o custo estimado por ressarcimento foi significativamente menor do que aqueles estimados por diretriz (p<0,001) e por revisão de prontuário (p=0,006), sendo, assim, significativamente diferentes. Conclusão Na perspectiva do Sistema Único de Saúde, existe diferença significativa nos custos estimados quando se utilizam diferentes metodologias, sendo a estimativa por ressarcimento a que resulta em valores menores. Considerando que não há diferença nos valores de custos estimados por diferentes metodologias de microcusteio, a metodologia de custeio por diretriz, de mais fácil e rápida execução, é uma alternativa válida para estimativa de custos de hospitalização por pneumonias bacterianas em crianças.

Eficiencia de los procesos administrativos para la gestión del Fondo de Protección contra Gastos Catastróficos en México / Administrative efficiency in the Mexican Fund for the Prevention of Catastrophic Expenditures in Health

Resumen: Objetivo: Mostrar que el régimen administrativo de hospitales de especialidad influye en la eficiencia de los procesos administrativos para operar el Fondo de Protección contra Gastos Catastróficos (FPGC), para la atención de cáncer de mama, cáncer cérvicouterino y leucemia linfoblástica aguda. Material y métodos: La variable para estimar la eficiencia del proceso administrativo fue el tiempo entre la notificación del caso y el reembolso. Para su estimación se realizaron entrevistas semiestructuradas con actores clave involucrados en la gestión de casos financiados por el FPGC. Se organizó también un grupo de expertos para emitir recomendaciones de mejora. Resultados: Los hospitales de especialidad con un esquema descentralizado mostraron menor tiempo en el proceso administrativo en contraste con el modelo administrado por los Servicios Estatales de Salud, donde los tiempos fueron mayores y donde hubo mayores niveles de intermediación. Conclusiones: El modelo de hospitales especializados con un esquema descentralizado es más eficiente debido a que tiene mayor autonomía.

Abstract: Objective: To show that the administrative regime of specialized hospitals has some influence on the administrative processes to operate the Mexican Fund for Catastrophic Expenditures in Health (FPGC, in Spanish), for providing health care to breast cancer, cervical cancer and child leukemia. Materials and methods: The variable for estimating administrative efficiency was the time estimated from case notification to reimbursement. For its estimation, semistructured interviews were applied to key actors involved in management of cancer care financed by FPGC. Additionally, a group of experts was organized to make recommendations for improving processes. Results: Specialized hospitals with a decentralized scheme showed less time to solve the administrative process in comparison with the model on the hospitals dependent on State Health Services, where timing and intermediation levels were higher. Conclusions: Decentralized hospitals administrative scheme for specialized care is more efficient, because they tend to be more autonomous.

Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System / Custos das Cirurgias Cardíacas Segundo o Risco Pré-Operatório no Sistema Público de Saúde Brasileiro

AbstractBackground:Heart surgery has developed with increasing patient complexity.Objective:To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).Method:All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.Results:Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.Conclusion:Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

ResumoFundamentos:A cirurgia cardíaca evoluiu progressivamente com o aumento da complexidade dos pacientes.Objetivo:Avaliar a utilização de recursos e o custo real segundo o grupo de risco dos pacientes submetidos à cirurgia cardíaca, e compará-los com o valor ressarcido pelo Sistema Único de Saúde (SUS).Método:Foram analisadas todas as cirurgias cardíacas realizadas entre janeiro e julho de 2013 em um centro terciário. Dados demográficos e clínicos permitiram o cálculo do valor ressarcido pelo SUS. Os pacientes foram estratificados em baixo, médio e alto risco pelo EuroSCORE. Os resultados clínicos, o uso de recursos e os custos (real versus SUS) foram comparados entre os grupos de risco estabelecidos.Resultados:Taxas de mortalidade pós-operatória de baixo, intermediário e alto risco apresentaram correlação linear positiva (EuroSCORE: 3,8%, 10% e 25%, respectivamente; p < 0,0001), assim como a ocorrência de alguma complicação pós-operatória (EuroSCORE: 13,7%, 20,7% e 30,8%, respectivamente; p = 0,006). O tempo de internação aumentou de 20,9 para 24,8 e 29,2 dias, respectivamente (p < 0,001). O custo real foi paralelo ao aumento da utilização de recursos, segundo o EuroSCORE (R$ 27.116,00 ± R$13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectivamente; p < 0,001). O ressarcimento do SUS também aumentou (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$ 935,00; p < 0,001). Mesmo com aumento do EuroSCORE, houve diferença (p < 0,0001) progressiva entre o incremento do custo real e o ressarcimento do SUS.Conclusão:O aumento do EuroSCORE esteve relacionado a maiores morbimortalidade, tempo de internação e custos no pós-operatório. Embora o ressarcimento do SUS também aumente conforme o risco, ele não é proporcional ao custo real.

The process by which new health technology is listed for insurance coverage

Whether or not insurance covers new health technology has a great effect on the extent of its acceptance and diffusion. Thus many stakeholders vie to participate in determining insurance reimbursement regulations. This paper explains the process by which new health care technology is added to the coverage list in the Republic of Korea,with each checkpoint explained. Our paper also argues that the implication of the listing process of Korean insurance coverage should be modified in the area such as what is the principle of insurance coverage and who will decide the acceptance criteria of health technology, safety, effectiveness, economic feasibility, and relative value.

Análise de custos da assistência à saúde aos portadores de diabetes melito e hipertensão arterial em uma unidade de saúde pública de referência em Recife - Brasil / Analysis of health care costs of patients with diabetes mellitus and hypertension in a public health reference unit in Recife - Brazil

OBJETIVO: Analisar os custos para a assistência à saúde de portadores de diabetes melito e hipertensão arterial e estimar o custo de procedimentos ambulatoriais de média complexidade comparando-os com os valores da tabela de reembolso do Sistema Único de Saúde (SUS). MATERIAIS E MÉTODOS: Foram analisados os custos diretos sanitários, em unidade pública de referência em Recife/PE no ano de 2007. Para o levantamento e alocação dos custos, utilizaram-se as técnicas de custeio por absorção e de rateio. RESULTADOS: Os custos diretos e o valor reembolsado pelo SUS totalizaram R$ 4.855.291,82 e R$ 2.118.893,56, respectivamente. Os grupos de despesas que apresentaram maiores custos foram: medicamentos R$ 1.762.424,42 (36,3 por cento), serviços de terceiros R$ 996.637,82 (20,5 por cento) e pessoal R$ 978.096,10 (20,1 por cento). Todos os procedimentos apresentaram maior custo estimado que os valores pagos pela tabela SUS. CONCLUSÕES: Os medicamentos representaram os maiores custos para assistência e identificou-se diferença considerável entre os custos estimados e os valores reembolsados pelo SUS.

OBJECTIVE: To analyze health care costs of patients with diabetes mellitus and hypertension, and to estimate the cost of medium complexity outpatient procedures, compared with the standard reimbursement values used in Brazil. MATERIALS AND METHODS: We analyzed direct health costs in a public health reference unit in Recife/PE, in 2007. Costs were determined and allocated using the techniques of absorption costing and apportionment. RESULTS: Direct costs and the amount reimbursed by the SUS totaled R$ 4,855,291.82 and R$ 2.118.893,56, respectively. The greatest groups of expenditure were medications, with R$ 1,762,424.42 (36.3 percent), outsourced services, with R$ 996,637.82 (20.5 percent); and personnel, with R$ 978,096.10 (20.1 percent). All procedures had higher estimated costs than what is reimbursed by the SUS. CONCLUSIONS: Drugs were associated with the highest health care costs, a considerable difference was observed between estimated costs and the amount reimbursed by the SUS.

China's oral care system in transition: lessons to be learned from Germany / 国际口腔科学杂志·英文版

<p><b>AIM</b>The objective of this discussion paper is to investigate whether the experience gained through the German paradigm shift in dental care can be of benefit in China's deliberations on the introduction of universal dental care for its people. METHODOLOGY A comparison of representative oral health outcome data from China and Germany, two countries at different stages in their development, is presented here in order to analyse whether the findings meet expected outcome and confirm the presumption that more developed countries perform better.</p><p><b>RESULTS</b>The epidemiological comparison reveals surprising findings concerning the severity of dental diseases and, in particular, missing teeth per person in adults and rates of total edentulousness in seniors. In all of these areas German adults and seniors show significantly inferior outcomes compared with the Chinese population. The main reason for these striking discrepancies, as it turned out, is the decisive role played by the treatment philosophies and strategies of German dentists.</p><p><b>CONCLUSION AND RECOMMENDATIONS</b>If dentists take a less interventionist approach, checking as well as treating dental diseases with preventive and strictly tooth-preserving methods, dental treatment results in oral health. Under these conditions it can be assumed that modern dentistry is generally good for the teeth. These findings are important for developing countries that are seeking to integrate dental care into their health care system. On the basis of long-term experience from highly industrialized Western countries and especially from Germany we will attempt to put forward proposals for creating an effective and efficient dental care system in China.</p>

Internações por pé diabético: comparação entre o custo direto estimado e o desembolso do SUS / In hospital care for diabetic foot: a comparison between the estimated cost and the SUS reimbursement

Foram seguidas 109 internações de pacientes com diabetes e ulcerações nos pés na rede do Sistema Único de Saúde (SUS) em Sergipe, com o objetivo de estimar o custo direto hospitalar e comparar com os valores do desembolso do SUS. Os dados foram coletados desde a admissão até a alta ou o óbito dos casos incluídos, sendo anotadas as características clínicas dos pacientes e os desfechos das internações. Foram calculados o custo direto estimado e o desembolso do SUS. Todos eram portadores de diabetes tipo 2 e a maioria das ulcerações (64,2 por cento) foram classificadas como Wagner 4 ou 5. Evoluíram com alta sem amputação 43 pacientes (39,4 por cento) e 52 (47,7 por cento) com alta após amputação. Evoluíram para óbito 14 pacientes (12,8 por cento). O custo estimado variou de R$ 943,72 a R$ 16.378,85, com média de R$ 4.461,04. O valor do desembolso do SUS variou de R$ 96,95 a R$ 2.410,18, com média de R$ 633,97, cerca de sete vezes inferior. As menores defasagens entre os custos ocorreram nos pacientes assistidos no Hospital Beneficente e as maiores naqueles tratados com amputações menores.

This study aimed to analyze costs for treating patients with diabetic foot cared by the public Brazilian Health System (SUS), comparing the estimated cost with the amount of SUS reimbursement. A cohort prospective study carried out in hospitals that provide services for the Unified Health System in Sergipe, involving 109 hospitalization episodes of patients with diabetes and foot ulcers. We follow these patients day by day and estimated the hospital direct cost and the SUS reimbursement. All patients had type 2 diabetes and the majority of ulcers (64,2 percent) were classified as Wagner 4 or 5. Forty-three (39,4 percent) healed without amputation and fifty-two (47,7 percent) healed with amputation. Fourteen (12,8 percent) patients died. Hospital direct cost ranged from R$ 943.72 to R$ 16,378.85; with an average of R$ 4,461.04. The SUS reimbursement varied from R$ 96.95 to R$ 2,410.18, with an average of R$ 633.97, usually seven times low. Smaller difference between costs occurred in patients from the Beneficent hospital and higher rates occurred in those treated with minor amputation.

Test on the Cost and Development on the Payment System of Home Health Care Nursing / 간호학회지

PURPOSE: This study focused on analysing costs per home health care nursing visit based on home health care nursing activities in medical institutes. METHOD: The data was collected in three stages. First, the cost elements of home health care nursing services were collected and 31 home care nurses participated. Second, the workload and caseload of home care nursing activities were measured by the Easley-Storfjell Instrument(1997). Third, the opinions on improving the home health care nursing reimbursement system were collected by a nation-wide mailing survey from a total of 125 home care agencies. RESULT: The cost of home health care nursing per visit was calculated as 50,626 won. This was composed of a basic visiting fee of 35,090 won (about 35 dollars) and travel fee of 15,536 won (about 15 dollars). The major problems of the home care nursing payment system were the low level of the cost per visit, no distinction between first visit and revisits, and the limitations in health insurance coverage for home health care nursing services. CONCLUSION: This study's results will contribute as a baseline for establishing policies for improvement of the home health care nursing cost and for applying a community-based visiting nursing service cost.

Régimen legal de la seguridad social / Legal régime of the social security

El documento proporciona la cuarta edición del "Régimen legal de la seguridad social Nicaragüense", la que contiene la Ley Orgánica y su reglamento, Tabla por salario mensual y cotizaciones según categoría e indicaciones sobre su uso; Ley 340: "Ley de sistema de ahorro para pensiones"y su reglamento (decreto No. 55- 2000); Reglamento de inversiones para el sistema de ahorro para pensiones (Decreto No. 56- 2000) y sus reformas; Reglamento de certificado de traspaso (decreto No. 57- 2000) y sus reformas; Reglamento de la comisión calificadora de invalidez (decreto No. 89- 2000); Ley No. 388: "Ley orgánica de la superintendencia de pensiones"y su reglamento (decreto No. 64- 2001);Reglamento de inversion de los fondos de pensiones en el extranjero (decreto No. 53- 2001)

Nutriçäo enteral precoce reduz tempo de internaçäo hospitalar e melhora reembolso diário do Sistema Unico de Saúde (SUS) ao hospital / Early enteral nutrition reduces length of hospital stay and improves daily financial reimbursement from Public Health System to the hospital

A nutriçäo enteral precoce (NEP) pode diminuir complicaçöes infecciosas, melhorar cicatrizaçäo e conseqüêntemente reduzir o tempo e o custo da internaçäo. O objetivo do presente estudo foi demonstrar o efeito da NEP sobre o tempo de internaçäo e seu impacto no reembolso do Sistema Unico de Saúde (SUS) ao hospital. Foram avaliados 64 pacientes intenados na UTI no Hospital Geral de Pedreira. Os pacientes foram pareados em dois grupos: grupo nutriçäo enteral precoce (NEP) e grupo nutriçäo enteral tardia (NET). Considerou-se NEP quando iniciada a terapia nutricional em até 72 horas após internaçäo. Os seguintes dados foram coletados: idade, sexo, tempo de internaçäo e valor do reembolso do tratamento pelo SUS. Análise estatística apropriada foi aplicada considerando-se p menor que 0,05. No grupo NEP ocorreu menor tempo de internaçäo e melhorado reembolso diário ao hospital. Diante dos resultados obtidos pode-se inferir que a nutriçäo enteral precoce reduz o tempo de internaçäo hospitalar e proporciona melhor reembolso diário do SUS ao hospital.(au)

Expenditure and payment sources for treating acute respiratory infections in rural Vietnam.

This paper highlights important effects of the health sector reform in rural Vietnam, such as the expenditure for treatment, payment sources among patients and provision of private services. Using a cross-sectional design with a structured questionnaire, the occurrence of illnesses and utilization of health care for 4,769 members in randomly selected households were investigated, with a focus on acute respiratory infections (ARI). Three hundred and seventy people were reported to have suffered from an ARI in the four weeks prior to interview. In 96% of the cases some action had been taken, most often self-medication. The average expenditure for the first treatment was high, 25,000 Dong (US$ 1.7), which is appropriately equal to one third of the monthly per capita in the district. The majority of the expenditure was for drug purchasing in the private or public services. Expenditure for treatment of acute respiratory infections was highest in the hospitals, lower in commune health stations and private clinics, and lowest in the case of self-medication. There was no consultation fee at the commune health stations and private clinics. About half of the patients had borrowed money or sold agricultural products to pay for treatment. Only 2% of the patients benefited from health insurance. High burden of ARI, high cost of treatment and poor coverage of health insurance may create severe economic problems in poor families. Our findings indicate a need to develop pre-payment schemes and the appropriate allocation of resources in order to establish an efficient and equitable health care system.