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.

Community health insurance schemes & patient satisfaction - evidence from India.

Background & objectives: Quality of care is an important determinant for utilizing health services. In India, the quality of care in most health services is poor. The government recognizes this and has been working on both supply and demand aspects. In particular, it is promoting community health insurance (CHI) schemes, so that patients can access quality services. This observational study was undertaken to measure the level of satisfaction among insured and uninsured patients in two CHI schemes in India. Methods: Patient satisfaction was measured, which is an outcome of good quality care. Two CHI schemes, Action for Community Organisation, Rehabilitation and Development (ACCORD) and Kadamalai Kalanjiam Vattara Sangam (KKVS), were chosen. Randomly selected, insured and uninsured households were interviewed. The household where a patient was admitted to a hospital was interviewed in depth about the health seeking behaviour, the cost of treatment and the satisfaction levels. Results: It was found that at both ACCORD and KKVS, there was no significant difference in the levels of satisfaction between the insured and uninsured patients. The main reasons for satisfaction were the availability of doctors and medicines and the recovery by the patient. Interpretation & conclusions: Our study showed that insured hospitalized patients did not have significantly higher levels of satisfaction compared to uninsured hospitalized patients. If CHI schemes want to improve the quality of care for their clients, so that they adhere to the scheme, the scheme managers need to negotiate actively for better quality of care with empanelled providers.

Saúde suplementar / Supplemental health

Um dos desafios encontrados nos últimos anos para os gestores da área da saúde tem sido a regulação do setor de saúde suplementar e o estabelecimento da necessária interface com o SUS. Neste livro a regulamentação do setor de planos e seguros de saúde no Brasil é apresentada de forma detalhada com a apresentação das características gerais do sistema de saúde no Brasil, com a situação atual do mercado de saúde suplementar e o papel da ANS. O livro traz também informações atualizadas sobre o ressarcimento dos planos de saúde, a cobertura por região e o faturamento das operadoras, e a recente ampliação de procedimentos previstos. Nele, são abordadas as interfaces do setor de saúde suplementar com o Sistema Único de Saúde (SUS) e os mecanismos de articulação instituciona.

Implicações dos planos e seguros de saúde sobre o trabalho médico / Implications of health plans and insurance on the medical work

Buscou-se identificar prováveis implicações das normas e procedimentos dos planos e convênios de saúde no Brasil na autonomia do trabalho médico. Para tanto, foram realizadas entrevistas com médicos cujas especialidades garantiram a representatividade de três dos quatro grupos sociológicos de especialidades: cognitivas (clínicas), intermediárias (clínico-cirúrgicas) e técnico-cirúrgicaas (cirúrgicas). Concluiu-se que a autonomia técnica e a relação médico-paciente sofrem forte ingerência das empresas de asseguramento.

Seguro médico gratuito de vejez: "disposiciones legales que norman su aplicación" / Free health insurance of old age: \"legal provions that govern its application\"

Los resultados conseguidos hasta el presente, se traducen en que el proceso de inscripción y afiliación de las personas mayores de 60 años se va cumpliendo de manera positiva y ascedente tanto en los Municipios como en las Cajas de Salud de todos los departamentos del país, demostrando plenamente su viabilidad y garantizando para el benefiario un servicio de salud integral, brindando protección, atención, rehabilitación y estímulo social. En síntesis, el Seguro Médico Gratuito de Vejez, se constituye en la política social mas visible y significativa que está siendo impulsada por el Gobierno Nacional, susceptible de seguir generando un impacto progresivo positivo en la sociedad boliviana y de manera particular en las personas de la tercera edad

Normas estandarizadas de atención odontológica en las entidades gestoras de seguros de salud / Standarized norms dentistry care in the institutions of health insurances

El documento recoge y sistematiza las espectativas de trabajo de los profesionales odontológos que a partir de la misma desarrollan una nueva forma y cultura de trabajo, acorde a los avances de la ciencia y la tecnología

study on health services provided by student health insurance in some preparatory school clinics in Alexandria

This study assesses resources and services provided by school clinics during scholastic year 1993-1994. In addition, it examines student utilization of clinics, and their opinion and suggestions to improve the clinic services. Twelve preparatory school clinics were selected randomly. Interviews were conducted with school physicians and students. Four checklists were prepared for the necessary items of clinic resources. Results indicated that 75% of physicians were general practitioners half of them had poor knowledge regarding preventive aspect of their job responsibilities. All or most items of facilities for health education were lacking in the studied clinics. All school clinics provide curative services and 11 out of 12 carried out comprehensive school examination for their students. Screening and nutrition supervision were provided only in two clinics. It appeared that 76.6% of students visited the clinic during the scholastic year 1993-1994. A significant relation was found between students scholastic year and their visit of the clinic. It was found that 42.7% of students complained of absence of some drugs, while 24.7% of students suggested that coordination between time scheduled for visiting the clinic and class schedule is required. However, 66.4% of students expressed that student health insurance is better than the previous school health services

Study of referral process between general practitioners and specialists in health insurance clinics in Alexandria

The present study was designed to investigate the reasons for which patients are referred by G.Ps to GM. speciatists and to assess the extent to which referred cases need specialist care. The study sample included specialists of general medicine working at 4 of the H.I.O. and all G.Ps who referred cases that were considered as inappropriate referrals by the study specialists, as well as 20% of Patients referred to G.M. specialists by G.Ps were systematically randomly selected during a period of 10 consecutive days. The results indicated that the rate of inappropriate referral to G.M. specialists was high, the rate of discrepancy between G.P. and specialist diagnoses was generally high, there was a high discrepancy between G.Ps and specialists regarding the reason for inappropriate referral, and there was poor communication from the lower [G.P.] to the higher [specialists] levels in the referral process. Reasons for referral to specialists were not recorded by G.Ps in 100% of cases. To overcome these problems H.I.O. should place special emphasis on the professional training and continuing education of G.Ps, with special attention to the few common conditions that were responsible for the greater proportion of referral problems. At the same time, H.I.O. should strengthen the technical and administrative control over G.P. referral behavior

Effect of an asthma clinic run by the general practitioners on patient's morbidity in the health insurance in Ismailia

The aim of this study was to assess the effect of an asthma clinic run by general practitioners on patients morbidity, process of care and prescribing for asthma. Seventy asthma patients were studied. Comparisons were done before and 6 months after the intervention. Morbidity was measured in terms of frequency of the asthma attacks, night asthma, days off-work lost, as well as the values of peak flow rates measured by the peak flow meter. Results have shown a statistically significantly decreasing trend in morbidity [P <0.001]. Also, significant reductions were found in the patients requirement to corticosteroid [P <0.01] and the work-days lost [P <0.0001]. Significant improvements in the patients knowledge about asthma and in the inhaler technique were observed after the intervention. Lastly, the use of inhaler bronchodilators and steroids and of prophylactic medication has increased significantly