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.

Transferring the financial risks of pharmaceutical benefits from a large health care provider in Argentina to a consortium of pharmaceutical companies

OBJECTIVE: The National Institute of Social Services for Retirees and Pensioners (NISSRP) is a nationwide health care financing agency and service provider in Argentina. Among its services, the NISSRP provides outpatient drug coverage to more than 3.3 million beneficiaries, mainly senior citizens and disabled persons. In 1997, to help cope with its rising costs, the NISSRP agreed to transfer the risk for the cost of outpatient medications and cancer-treatment drugs to a consortium of pharmaceutical companies in exchange for a fixed monthly payment. The objective of this study was to determine the impact that this new approach had on three things: (1) the level of expenditures for the medicines that were included in the agreement, (2) the pattern of nonrational prescribing for NISSRP beneficiaries, and (3) this pattern's relationship with macroeconomic variables and the pattern of prescribing for Argentina as a whole. METHODS: We compared outpatient-medicine consumption in 1999 with consumption before the agreement went into effect. RESULTS: The actual amount that NISSRP beneficiaries spent out-of-pocket climbed from US$ 336.13 million in 1996 to US$ 473.36 million in 1999, an increase of almost 41 percent. The nominal amount "spent" by the NISSRP in 1999 was US$ 601.11 million, versus a real amount of US$ 374.75 million in 1996, an "increase" of 60 percent (that increase for the NISSRP was only theoretical since the agreement specified the fixed monthly amount that the NISSRP would have to pay to the pharmaceutical consortium). In contrast with the increased real spending by NISSRP beneficiaries, Argentina's economy remained stable over the assessed period, with the consumer price index even falling by 0.8 percent. We found high levels of nonrational drug use in the NISSRP system in both 1996 and 1999, indicating a serious ongoing problem. CONCLUSIONS: An agreement with pharmaceutical companies, like the one we have described, might add an element of financial predictability for institutions such as the NISSRP. However, such an agreement can easily result in an increased economic burden for health care beneficiaries, and without any improvement in the services that they receive. This type of agreement requires extensive mechanisms for control, follow-up, and updating, and it also risks making nonrational drug prescribing the accepted rule. While perhaps feasible, the requirements for this kind of agreement are actually very difficult to put into...