An Overview of the Risk Sharing Management in Korean National Health Insurance, Focused on the Effect of the Patient Access and Insurance Finance

OBJECTIVE: This study examined the Risk Sharing Agreement (RSA) on pharmaceutical pricing system in Korean national health insurance. Through RSA, the insurer was able to maintain the principles in the price listing process while managing the budget effectively and improving patient access to new drugs. Despite these positive effects, there are still issues raised by some stakeholders, such as lack of transparency in the listing process and doubts about its effectiveness. Therefore, we investigated the impacts of RSA on national health insurance financing and patient access to analyze the effects of RSA. METHODS: The impact of RSA was investigated by analyzing the health insurance claims data for 2014~2016. The degree of improvement in patient access was determined by the decreased amount of patients' payment. RESULTS: Results showed that the financial impact of RSA was not significant and patients' access to the new drug greatly improved. CONCLUSION: These results show that RSA is a good system for improving patient access to new drugs without additional expense on insurance.

Advanced medical devices and regulatory innovations in new health technology assessments

Advances in technology lead to advances in medical devices, and these advances have the positive effect of creating opportunities for beneficial developments in healthcare, such as innovating traditional healthcare processes or expanding opportunities for diagnosing and treating diseases. Nonetheless, device developers, suppliers, users, insurers, and patients all face the challenge of balancing patient safety and health effectiveness with a reasonable profit. In Korea, the New Health Technology Assessment system aims to introduce safe and effective health technology, but this is only effective for the entry of devices onto the healthcare market. This system is not enough for creating a healthy ecosystem in which high-quality technologies and devices survive in the market and naturally exit from the market if not successful. The nation must not lag in the rapid development of medical devices, but the concomitant requirement for patient safety is like two rabbits moving in different directions. There is not enough time to resolve each source of uncertainty for both developers and users. The early adoption of health technologies, including medical devices, offers new opportunities for treatment and diagnosis, but also poses unexpected health risks. Thus, we need to design a plan to generate scientific evidence related to medical devices after they introduced into practice. Additionally, regarding the use of individual medical devices, we believe that the creation of a healthy ecosystem for medical devices by implementing medical device surveillance culture is a way to manage the opportunities and risks of the early introduction of innovative medical devices.

The criteria for metabolic syndrome and the national health screening and education system in Japan / 한국역학회지

Two major definitions of metabolic syndrome have been proposed. One focuses on the accumulation of risk factors, a measure used by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI); the other focuses on abdominal obesity, a measure used by the International Diabetes Federation (IDF) and the Japanese government. The latter definition takes waist circumference (WC) into consideration as an obligatory component, whereas the former does not. In 2009, the IDF, NHLBI, AHA, and other organizations attempted to unify these criteria; as a result, WC is no longer an obligatory component of those systems, while it remains obligatory in the Japanese criteria. In 2008, a new Japanese cardiovascular screening and education system focused on metabolic syndrome was launched. People undergoing screening are classified into three groups according to the presence of abdominal obesity and the number of metabolic risk factors, and receive health educational support from insurers. This system has yielded several beneficial outcomes: the visibility of metabolic syndrome at the population level has drastically improved; preventive measures have been directed toward metabolic syndrome, which is expected to become more prevalent in future generations; and a post-screening education system has been established. However, several problems with the current system have been identified and are under debate. In this review, we discuss topics related to metabolic syndrome, including (1) the Japanese criteria for metabolic syndrome; (2) metabolic syndrome and the universal health screening and education system; and (3) recent debates about Japanese criteria for metabolic syndrome.

The criteria for metabolic syndrome and the national health screening and education system in Japan / 한국역학회지

Two major definitions of metabolic syndrome have been proposed. One focuses on the accumulation of risk factors, a measure used by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI); the other focuses on abdominal obesity, a measure used by the International Diabetes Federation (IDF) and the Japanese government. The latter definition takes waist circumference (WC) into consideration as an obligatory component, whereas the former does not. In 2009, the IDF, NHLBI, AHA, and other organizations attempted to unify these criteria; as a result, WC is no longer an obligatory component of those systems, while it remains obligatory in the Japanese criteria. In 2008, a new Japanese cardiovascular screening and education system focused on metabolic syndrome was launched. People undergoing screening are classified into three groups according to the presence of abdominal obesity and the number of metabolic risk factors, and receive health educational support from insurers. This system has yielded several beneficial outcomes: the visibility of metabolic syndrome at the population level has drastically improved; preventive measures have been directed toward metabolic syndrome, which is expected to become more prevalent in future generations; and a post-screening education system has been established. However, several problems with the current system have been identified and are under debate. In this review, we discuss topics related to metabolic syndrome, including (1) the Japanese criteria for metabolic syndrome; (2) metabolic syndrome and the universal health screening and education system; and (3) recent debates about Japanese criteria for metabolic syndrome.

Accidentes de trabajo y enfermedades laborales en los sistemas de compensación laboral / Work accidents and occupational diseases in work compensation systems

Introducción: Las contingencias laborales constituyen un importante problema de salud pública en el mundo. Para reducir los daños, los países han introducido leyes y normas técnicas para la prevención de las mismas y reparación de las víctimas a través de seguros de compensación laboral y atención médica integral. Objetivo: Conocer el nivel de evidencia existente sobre los accidentes de trabajo y enfermedades profesionales compensados y las características de los trabajadores que los presentaron e industrias más afectadas. Métodos: Se realizó una revisión sistemática bajo la metodología "Prisma". La búsqueda bibliográfica se llevó a cabo en bases de datos y revistas científicas a través de palabras claves que fueron combinadas y restringidas a artículos publicados entre los años 2003 y 2013. Resultados: Se incluyeron 11 artículos de investigaciones que fueron realizadas en cuatro continentes: Europa, Asia, Oceanía y América. Los tipos de estudios fueron, principalmente, retrospectivos con fuentes secundarias. Las muestras variaron entre 307 hasta 1.320.792 registros en diferentes grupos poblacionales, que tuvieron una o múltiples reclamaciones de compensación por accidentes de trabajo y/o enfermedades laborales. El género masculino tuvo el porcentaje más alto de reclamaciones; las industrias más afectadas fueron la manufactura y la construcción; predominaron como primera causa los esguinces o torceduras, seguidos por los trastornos musculoesqueléticos. Conclusiones: Las investigaciones revisadas proporcionan informaciones para caracterizar las contingencias ocupacionales y orientar las estrategias de prevención en las industrias y en las poblaciones trabajadoras más afectadas. Sin embargo, tienen limitaciones para establecer la gravedad de las lesiones y los tipos de compensación otorgados.

Introduction: Occupational injuries constitute an important problem of public health in the world. In order to reduce damage, countries have introduced laws and technical standards for their prevention, and to provide the victims support by means of worker's compensation insurance and comprehensive health care. Objective: To know the existing evidence level of work accidents and compensated occupational diseases and the characteristics of workers who presented them, and the most affected branches of industries. Methods: A systematic review following the "Prisma" methodology was conducted. The bibliographic research was carried out in databases and scientific journals through keywords that were combined and restricted to articles published between 2003 and 2013. Results: Eleven articles about researches conducted in four continents (Europe, Asia, Oceania and America) were included. The studies were mainly retrospective with secondary sources, and the samples ranged from 307 to 1,320,792 records in different population groups, who had one or multiple claims of compensation for work-related accidents or illnesses. The male gender had the highest percentage of claims; the most affected industries were manufacture and construction; the first causes were sprains and strains followed by musculoskeletal disorders. Conclusions: The reviewed investigations provide information to characterize the occupational contingencies and to orient the strategies of prevention in the industries and in the most affected working population. However, there are limitations to establish the seriousness of the injuries and the types of compensation awarded.

The Effect of Mandatory Diagnosis-Related Groups Payment System / 보건행정학회지

BACKGROUND: The voluntary diagnosis-related groups (DRG)-based payment system was introduced in 2002 and the government mandated participation in the DRG for all hospitals from July 2013. The main purpose of this study is to examine the independent effect of mandatory participation in DRG on various outcomes of patients. METHODS: This study collected 1,809,948 inpatient DRG data from the Health Insurance Review and Assessment database which contains medical information for all patients for the period 2007 to 2014 and examined patient outcomes such as length of stay (LOS), total medical cost, spillover, and readmission rate according to hospital size. RESULTS: LOS of patients decreased after DRGs (large hospitals: adjusted odds ratio [aOR], 0.87; 95% confidence interval [CI], 0.78-0.97; small hospitals: aOR, 0.91; 95% CI, 0.91-0.92). The total medical cost of patients increased after DRGs (large hospitals: aOR, 1.22; 95% CI, 1.14-1.30; small hospitals: aOR, 1.22; 95% CI, 1.21-1.23). The results reveals that spillover of patients increased after DRGs (large hospitals: aOR, 1.27; 95% CI, 0.70-2.33; small hospitals: aOR, 1.18; 95% CI, 1.16-1.20). Finally, we found that readmission rates of patients decreased significantly after DRGs (large hospitals: aOR, 0.28; 95% CI, 0.26-0.29; small hospitals: aOR, 0.59; 95% CI, 0.56-0.63). CONCLUSION: The DRG payment system compared to fee-for-service payment in South Korea may be an alternative medical price policy which can reduce the LOS. However, government need to monitor inappropriate changes such as spillover increase. Since this study also is the results based on relatively simple surgery, insurer needs to compare or review bundled payment like new DRG for expansion of various inpatient-related diseases including internal medicine.

Impacto de la utilización de la red propia de una aseguradora privada sobre los costos de atención ambulatoria / The cost impact of a private insurer's own network upon outpatient care

Objetivo. Medir el impacto de la red propia (proveedores verticalmente integrados) de una aseguradora privada sobre los costos médicos ambulatorios de sus asegurados, a través de un análisis econométrico. Se busca verificar si un mayor uso de la red propia reduce los costos en los que la aseguradora incurre, de acuerdo con lo que sugiere la literatura especializada. Material y métodos. Estudio basado en una regresión lineal múltiple sobre los datos de una aseguradora privada. La variable dependiente es el costo per cápita de los servicios ambulatorios. Las variables explicativas son la adherencia a la red propia y una serie de variables para especificar mejor el modelo. Resultados. En relación con la cobertura de los costos de atención ambulatoria, si los demás factores se mantienen constantes, se observa que los asegurados con alta adherencia a la red propia presentan menores costos de atención que aquéllos con baja adherencia. Conclusión. El proceso decisorio sobre qué servicios y en qué grado debe ser aplicado a cada persona, por condiciones particulares de la oferta como el hecho de reunir recurso humano en sedes propias bajo reglas formales, presenta un impacto en los costos de atención en salud. Condiciones particulares de la oferta producen variaciones en la forma como son empleados los recursos.

Objective. Econometric analysis that seeks to measure the cost impact of a private insurer's own network upon outpatient care for its policyholders, own network refers to vertical integrated providers. The purpose is to assess whether greater use of its own network reduces the costs that the insurer incurred, according to what specialized literature suggests. Materials and methods. Study based on a multiple linear regression on data from a private insurer. The dependent variable is per capita cost of outpatient services. The explanatory variables are adherence to the own network and a number of variables to specify better the model. Results. With all other factors constant, in relation to covering the costs of outpatient care, it is noted that policyholders with high adhesion to their own network are less expensive than whose with low adhesion. Conclusions. The decision-making process about what services and what grade should be applied to each person by special conditions of the offer as the aggregation of human resources in own offices under formal rules has an impact on health care costs. Particular supply conditions cause variations in how resources are used.

Urgent Reimbursement Need for Diabetes Supplies in Blood Glucose Management of Diabetic Patients / 임상당뇨병

To achieve long-term diabetic complication reduction and decrease the health care costs, all diabetic patients must have access to the components of diabetes care modality, such as medications, supplies, and self-management education programs. However, our current government policies for diabetic patients are not sufficient to allow for adequate blood glucose control. Our national insurer does not reimburse for diabetes supplies such as blood glucose testing monitors, blood glucose test strips, lancet devices and lancets, insulin syringes and pen needles, and alcohol swabs. The government officer states that national laws, regulations, executive order, and financial problems prohibit the reimbursement of diabetes supplies. However, to achieve good outcomes and decrease the public burden of medical care costs, all stake holders, health care professionals, and diabetic patients should exert effort to require reimbursement of diabetic supplies.

La quimera de los servicios de salud / The chimera of health services

Desde la mitad del siglo XIX comenzó a propagarse una idea confusa que consistía en llamar servicios de salud a la atención de pacientes, organizada predominantemente por compañías de seguros y por el Estado. Algo parecido ocurrió con los ministerios de higiene y salud pública que nacieron a principios del siglo XX, a los cuales en los años 40 les cambiaron de nombre, llamándolos Ministerios de Salud, aparentemente para proveer servicios destinados a proteger y mantener la salud de los habitantes de la nación. Lamentablemente, esto no fue lo que ocurrió, pues se convirtieron en ministerios para atender principalmente la enfermedad y sus consecuencias, relegando a su mínima expresión la promoción, la protección y el mantenimiento de la salud. Este ensayo analiza cómo ocurrió dicho cambio sin que la población se percatara de la falacia que esto representaba y las nefastas secuelas que ha ocasionado, como la iatrogénesis. Es necesario llamar las cosas por su nombre para no engañar a la sociedad y corregir el grave desequilibrio entre los servicios de salud y los servicios médicos. Se hace referencia a los verdaderos servicios de salud y se mencionan algunas repercusiones en la práctica médica y la educación médica.

In the mid-19th century a mystifying idea began to circulate that consisted in giving the name of health services to the medical care of patients organized predominantly by insurance agencies and the State. Something similar happened with the ministries of hygiene and public health that were created at the beginning of the 20th century; in the 1940’s their names were changed to health ministries, apparently to provide health services to protect and maintain the health of the population. Regrettably, this was not what happened, because they became ministries to take care mainly of disease and its consequences, relegating the promotion, protection and maintenance of health to their minimum expression. This paper analyzes how this change happened unnoticed by a deceived population, with ominous sequels, such as a rise in iatrogenesis. It is necessary to call things by their name in order not to deceive socie-ty and to correct the serious imbalance between medical services and health services. A summarized reference is made to true health services and certain implications for medicine and medical education are mentioned.

Work-related Musculoskeletal Disorders in Korea and Japan: A Comparative Description

OBJECTIVES: Work related Musculoskeletal disorders (WMSD) is one of the most important problem in occupational health system of Korea and Japan, where the OHS system developed in similar socio-cultural environment. This study compared WMSD in Korea and Japan to review similarities and differences in their historical background, and development of prevention policies. METHODS: Scientific articles, government reports, and related official and non-official statistics on WMSD since the 1960s in Japan and Korea were reviewed. RESULTS: The historical background and basic structure of the compensation system in Korea and Japan largely overlapped. The issuing of WMSD in both countries appeared as upper limb disorder (ULD), named occupational cervicobrachial diseases (OCD) in Japan, and neck-shoulder-arm syndrome (NSA) 30 years later in Korea, following the change from an industrial structure to automated office work. Both countries developed manuals for diagnosis, guidelines for workplace management, and prevention policies. At present, compensation cases per covered insurers for WMSD are higher in Korea than in Japan, due to the social welfare system and cultural environment. Prevention policies in Korea are enforced more strongly with punitive measures than in Japan. In contrast, the Japanese system requires autonomous effort toward risk control and management, focusing on specific risky processes. CONCLUSIONS: WMSD in Korea and Japan have a similar history of identification and compensation structure, yet different compensation proportions per covered insurer and prevention policies. Follow-up study with international cooperation is necessary to improve both systems.

Stratified Sampling Design Based on Data Mining / 대한의료정보학회지

OBJECTIVES: To explore classification rules based on data mining methodologies which are to be used in defining strata in stratified sampling of healthcare providers with improved sampling efficiency. METHODS: We performed k-means clustering to group providers with similar characteristics, then, constructed decision trees on cluster labels to generate stratification rules. We assessed the variance explained by the stratification proposed in this study and by conventional stratification to evaluate the performance of the sampling design. We constructed a study database from health insurance claims data and providers' profile data made available to this study by the Health Insurance Review and Assessment Service of South Korea, and population data from Statistics Korea. From our database, we used the data for single specialty clinics or hospitals in two specialties, general surgery and ophthalmology, for the year 2011 in this study. RESULTS: Data mining resulted in five strata in general surgery with two stratification variables, the number of inpatients per specialist and population density of provider location, and five strata in ophthalmology with two stratification variables, the number of inpatients per specialist and number of beds. The percentages of variance in annual changes in the productivity of specialists explained by the stratification in general surgery and ophthalmology were 22% and 8%, respectively, whereas conventional stratification by the type of provider location and number of beds explained 2% and 0.2% of variance, respectively. CONCLUSIONS: This study demonstrated that data mining methods can be used in designing efficient stratified sampling with variables readily available to the insurer and government; it offers an alternative to the existing stratification method that is widely used in healthcare provider surveys in South Korea.

Cost-effectiveness Analysis of Home Care Services for Patients with Diabetic Foot / 간호행정학회지

PURPOSE: This study was a retrospective survey to examine economic feasibility of home care services for patients with diabetic foot. METHODS: The participants were 33 patients in the home care services (HC) group and 27 in the non-home care services (non-HC) group, all of whom were discharged early after inpatient treatment. Data were collected from medical records. Direct medical costs were calculated using medical fee payment data. Cost-effectiveness ratio was calculated using direct medical costs paid by the patient and the insurer until complete cure of the diabetic foot. Effectiveness was the time required for a complete cure. Direct medical costs included fees for hospitalization, emergency care, home care, ambulatory fees, and hospitalization or ambulatory fees at other medical institutions. RESULTS: Mean for direct medical costs was 11,118,773 won per person in the HC group, and 16,005,883 won in the non-HC group. The difference between the groups was statistically significant (p=.042). Analysis of the results for cost-effectiveness ratio showed 91,891 won per day in the HC patients, and 109,629 won per day in the non-HC patients. CONCLUSION: Result shows that the cost-effectiveness ratio is lower HC patients than non-HC patients, that indicates home care services are economically feasible.

Perspectiva actual de la responsabilidad profesional en el ámbito psicológico-asistencial (aportes en materia de historia clínica y consentimiento informado según las nuevas normativas legales) / Present perspectives of professional responsibility in the psychological assistance area (contributions on medical history and informed consent according to norms of new legislation)

A partir de la declaración de los Derechos Humanos se han ido produciendo, progresivamente, cambios sociales y legislativos en pos de la defensa de las garantías de los derechos de las personas. Los Estados se han visto obligados a dar respuesta y a velar por tales valores. Salud mental no fue la excepción. Dada la complejidad de su especialidad, esta requiere de un esfuerzo de revisión minucioso a la hora de articular los correctos procedimientos asistenciales. Los juicios de responsabilidad profesional crecen en forma sostenida en la República Argentina en la última década y han modificado en forma sustancial el modo en el cual se ejerce la actividad asistencial en el país. De tal manera, los profesionales médicos han contratado en forma universal la prestación de seguros para el eventual juicio, Tales compañías, han implementado cursos de capacitación continua para mejorar las condiciones médico legales en los que se desarrolla la asistencia. Los médicos conocen los derechos de los pacientes, se enfatiza el mejor modo de redactar los registros escritos y se han extendido los comités de bioética. A su vez, han ido incorporando la previsión ante la eventualidad de un procesamiento judicial y adquieren los conceptos jurídicos que les permiten enfrentar situaciones de gran complejidad. En contraste, los profesionales psicólogos sostenemos una actitud que podría denominarse de “negación” ante la realidad de los tribunales de justicia actuales. Esta hipótesis encuentra sostén en la escasa bibliografía vinculada al tema escrita por psicólogos, lo cual no resulta consecuente con la responsabilidad que nos cabe como especialistas en trastornos mentales, orientación universitaria que nos impone un “saber” específico e intransferible y, gracias al cual, podemos obtener un sustento económico (lo cual desde luego conforma un contrato tácito con derechos y obligaciones como en cualquier otro contrato). Inmersos en este marco, es propósito de esta breve exposición, abordar dos temas centrales y críticos que atañen a la práctica cotidiana de la asistencia en psicopatología. Estos son: historia clínica y consentimiento informado

Future directions of chronic disease management in South Korea

In Korea, the proportion of medical costs due to chronic diseases among total health care expenditures is increasing rapidly. This trend calls for immediate countermeasures. In the major developed countries in Europe, a gatekeeper system has been adopted at the national level as a universal policy to manage and prevent chronic disease. In South Korea, insurers and local governments offer management programs to individuals with chronic disease and metabolic syndrome under the Korean government's Health Plan 2020, but these programs are fragmented and there are some related limitations. The role of the national government is very important to overcome this problem because the chronic disease management systems of other players (insurers, local governments) must be integrated. In addition, the expert patients program, which is intended to improve the self-care skills of chronic disease patients, needs to be better promoted. Incentives should include "mileage programs" in which patients can accumulate points for successful self-care. It is also important to increase public awareness through large-scale promotional campaigns. Finally, it is necessary to raise funds to conduct national-level campaigns and provide incentives to patients, and to ensure that all processes establish an organic cooperation system. Such practices will maximize the positive effects of a nationwide chronic disease management system in South Korea.

¿Por qué se limita la integración vertical en el sector salud en Colombia? / Por que é que se limita a integracao vertical no sector saúde na Colombia? / Why is vertical integration restricted in the Colombian health sector?

En el sector salud colombiano se busca limitar la integración vertical entre Entidades Promotoras de Salud (EPS) e Instituciones Prestadoras de Servicios de Salud (IPS), para evitar prácticas restrictivas de la competencia. Sin embargo, la evidencia empírica señala que no es concluyente el efecto de la integración vertical sobre la competencia entre aseguradoras. El trabajo plantea esta hipótesis sobre la base de la evidencia teórica y empírica, y muestra que la integración vertical no tuvo efectos sobre la competencia de las EPS del régimen contributivo en el período posterior a la aplicación de la restricción del 30% de contratación entre aseguradores y prestadores de servicios de salud...

In Colombia, the Health industry is restricted from vertically integrating the Health Management Organizations (EPS) with the Health Service Providers (IPS) in order to avoid antitrust competitive conditions. However, the empirical evidence in this regard is inconclusive. This paper analyzes this antitrust hypothesis, contrasting it to the empirical and theoretical evidence at hand, and shows that vertical integration had no effect on EPS competition in the period after the restriction on 30% contracting between both types of entities was enforced...

No sector saúde colombiano procura-se limitar a integração vertical entre Entidades Promotoras de Saúde (EPS) e Instituições Prestadoras de Serviços de Saúde (IPS) para evitar práticas restritivas da concorrência. No entanto, a evidência empírica indica que o efeito da integração vertical sobre a concorrência entre as companhias de seguros não é conclusivo. O trabalho levanta esta hipótese sobre a base da evidência teórica e empírica para mostrar que a integração vertical não teve nenhum efeito sobre a concorrência das EPS do regime contributivo no período após da aplicação da restrição de 30% de contratação entre as seguradoras e os prestadores dos serviços de saúde...

Feasibility of community-based health insurance in rural tropical Ecuador / Factibilidad de un seguro de enfermedad comunitario en una zona rural tropical de Ecuador

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50 percent of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3 percent. With affiliation, 92.2 percent of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

OBJETIVO: El objetivo principal de este estudio fue evaluar la voluntad de los habitantes de El Páramo, una zona rural en el Ecuador, de participar en un seguro de salud comunitario y determinar los factores que influían en dicha voluntad. Otro objetivo fue identificar la comprensión y las actitudes de la población hacia el modelo presentado. MÉTODOS: Se llevó a cabo una encuesta transversal usando un cuestionario estructurado. De unos 829 hogares, 210 se escogieron aleatoriamente mediante un muestreo por conglomerados en dos etapas. Se analizaron las actitudes hacia un esquema de seguro de enfermedad, se recopiló información sobre los factores que posiblemente influían en la voluntad de participar y se correlacionaron con esta última. Para comprender la posible capacidad de pago de un entrevistado, se evaluó el gasto en atención de la salud en el último episodio de enfermedad. Se definió "factibilidad" como la existencia de voluntad de participar en el esquema de seguro de enfermedad en al menos 50 por ciento de los jefes de hogar. RESULTADOS: La voluntad de participar en un modelo de seguro de enfermedad por un costo de US$ 30 por año fue de 69,3 por ciento. El 92,2 por ciento de los entrevistados declararon que, en el caso de adherirse al programa, concurrirían al establecimiento de salud local más a menudo. El nivel educativo presentó una correlación negativa con la voluntad de participar, pero otras variables no mostraron ninguna asociación significativa con ella. El estudio reveló una actitud positiva hacia el esquema del seguro de enfermedad. Se documentaron gastos de atención de salud importantes en el último episodio de enfermedad. CONCLUSIONES: La puesta en marcha de un seguro de enfermedad en la zona de estudio es factible. Sin embargo, es probable que la participación real sea inferior a la voluntad de participar declarada. Aun así, un esquema de seguro de enfermedad podría representar una opción financiera interesante en las zonas rurales donde los servicios son escasos y difíciles de mantener.

Características de la contratación entre aseguradores y prestadores de servicios de salud, Medellín, 2007-2008 / Características da contratação entre administradoras de planos de benefício e prestadores de serviços de saúde, Medellín, 2007-2008 / Characteristics of the Contracting out process between insurers and hospitals; Medellín 2007-2008

Objetivo: describir las características del proceso de contratación de servicios de salud entre las entidades administradoras de planes de beneficio - EAPB (Entidades Promotoras de Salud (EPS) y entes territoriales) con los Institutos Promotores de Salud (IPS) públicas y privadas en la ciudad de Medellín, entre los años 2007 y 2008. Metodología: se realizó un estudio descriptivo exploratorio; se analizó una muestra de minutas de contratos firmados entre EAPB e IPS, y se realizaron entrevistas en profundidad para identificar los aspectos relevantes del proceso de negociación y de las relaciones entre contratantes y contratistas. Hallazgos relevantes: las minutas de los contratos son muy diversas, se observa un desbalance en las obligaciones de las partes y hay constantes tensiones interinstitucionales relacionadas con la posición dominante de las EAPB.

Objective: to describe the characteristics of the health service contracting out process betweenAdministrator Entities of Benefit Plans – health Promoting Entities and Territorial Entities- with public and private Health Service Providers of Medellin city, between 2007 and 2008. Methodology:a descriptive, exploratory methodological approach was used to analyze a sample of the contract’s minutes and a qualitative approach to identify the relevant aspects of the negotiation process and the relationship between contractors and contracting parties in the development ofthe contracts. Main finding: the contract is a source of ongoing inter-institutional stress during the negotiation, development, and ending phases affected by the exercise of the underwriter´s dominant position of the health insurers opposed to the purpose of willing agreement guaranteeing effective access to health service.

Objetivo: descrever as características do processo de contratação de serviços de saúde entre as entidades administradoras de planos de benefício – EAPB (Entidades Promotoras de Saude(EPS) e entidades territoriais) com as organizações prestadoras (IPS) públicas e privadas na cidade de Medellín, entre os anos 2007 e 2008. Metodologia: realizou-se um estudo descritivo e exploratório; analisou-se um mostra de minutas de contratos assinados entre as entidadesadministradoras (EAPB) e as organizações prestadoras (IPS), e realizaram-se entrevistas aprofundidade para identificar os aspectos relevantes do processo de negociação e das relaçõesentre contratantes e contratados. Descobrimentos relevantes: as minutas dos contratos são muito diversas, observa-se um desequilíbrio nas obrigações das partes e há contastes tensões interinstitucionais relacionadas com a posição dominante das entidades administradoras (EAPB).