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.

Características generales de la educación médica en México. Una mirada desde las escuelas de medicina / General characteristics of medical education in Mexico. A look from medical schools

Resumen: Objetivo: Conocer las características de la educación médica e identificar sus fortalezas y debilidades. Material y métodos: Se realizó un estudio transversal y cuantitativo para conocer las características de la educación médica en 29 escuelas de medicina en México, entre abril y septiembre de 2017. Se utilizó un cuestionario con escala tipo Likert para explorar el contexto, la regulación, la estructura, el proceso, los resultados y el impacto de la educación médica. Se realizó un análisis bivariado con ji cuadrada y una significancia estadística depigual o menor a 0.05. Resultados: El contexto político obtuvo 64%, el contexto económico 10%, los mecanismos de regulación 31%, la estructura educativa 61% y el impacto social 93%. Conclusiones: Se requiere fortalecer las políticas públicas, la regulación y la inversión pública, para mejorar la calidad de la educación médica.

Abstract: Objective: To know the characteristics of medical education and identify its strengths and weaknesses. Materials and methods: A transversal and quantitative study of the characteristics of medical education in 29 medical schools in Mexico was carried out, between April and September 2017. Questionnaire with Likert scale was applied to explore context, regulation, structure, process, results and impact of medical education. Bivariate analysis was performed with a Chi square test and the significance level was equal to or less than 0.05. Results: The political context obtained 64%, economical context 10% and mechanisms of regulation 31%. The educational structure was 61% and the social impact was 93%. Conclusions: Public policies, regulatory mechanisms and public investment must be strengthened to improve the quality of medical education.

Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad / Certification of medical care facilities in Mexico: analysis of the incentives for its continuity

Resumen: Objetivo: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. Material y métodos: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. Resultados: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. Conclusiones: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.

Abstract: Objective: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. Materials and methods: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. Results: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. Conclusions: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

Medical perception of stroke care conditions in Brazil / Percepção médica sobre as condições para atendimento do AVC no Brasil

ABSTRACT Stroke is currently the second leading cause of death in Brazil. Neurologists' reports on the absence of adequate resources for stroke care are frequent; however, there are no objective data on this perception. Objective To assess the perception of neurologists of stroke care conditions in Brazil. Methods Neurologists from all over Brazil were surveyed by means of an anonymous questionnaire about the main shortcomings in stroke care, focusing particularly on physical structure and infrastructure (diagnostic methods, patient transport, availability of beds, multi-professional team). Results The main shortcomings are indicated: the worst conditions, among all items surveyed, were found in the public sector. In the private sector, conditions were better. Conclusions Care conditions are worse in the public sector with regard to both infrastructure and human resources. Future public health policies for the prevention and treatment of stroke should be formulated, taking into consideration neurologists' perceptions.

RESUMO O acidente vascular cerebral é atualmente a segunda causa de morte no Brasil. São frequentes os relatos de médicos neurologistas sobre a ausência de recursos adequados para o atendimento do AVC, no entanto, não existem dados objetivos sobre essa percepção. Objetivo Analisar a percepção de médicos neurologistas sobre as condições para o atendimento de AVC no Brasil. Métodos Neste estudo foi realizada pesquisa por questionário anônimo com médicos neurologistas de todo o Brasil, perguntando-se as principais deficiências para o atendimento, com foco na estrutura física, infraestrutura (métodos diagnósticos, transporte do doente, disponibilidade de leitos, equipe multiprofissional). Resultados As principais deficiências são apontadas; no setor público notou-se as piores condições, em todos os itens pesquisados. No setor privado, as condições são melhores. Conclusões As condições de atendimento são piores no setor público, tanto de infraestrutura quanto de recursos humanos. Futuras políticas de saúde pública para prevenção e tratamento do AVC deveriam ser elaboradas levando em consideração a percepção do neurologista.

Quality of the ophthalmological service to outpatients of the public and private healthcare systems / Qualidade do serviço oftalmológico prestado aos pacientes ambulatoriais dos sistemas de saúde público e privado

ABSTRACT Purpose: To compare perceptions of the quality of ophthalmological services offered to outpatients from the public healthcare system to those from the private healthcare system, and to determine which measures are seen as necessary and a priority for improving the quality of care. Methods: This was a prospective observational study on 200 patients, 101 and 99 of whom were from the public and private healthcare systems, respectively. All patients underwent an ophthalmological examination at an ophthalmology hospital in Belo Horizonte, Minas Gerais, Brazil. Personal interviews were conducted using two structured questionnaires adapted from the modified SERVQUAL scale. Results: Overall, patients from the private healthcare system were significantly more dissatisfied than those from the public healthcare system. In both systems, reliability was considered to be the most important determinant of quality, and it presented the highest level of dissatisfaction. Satisfaction with the public healthcare system was significantly greater than that with the private healthcare system in terms of the tangibles, reliability, responsiveness, and assurance determinants of the SERVQUAL scale. Conclusions: Institutions must plan, execute, evaluate, and monitor measures that seek to improve the overall patient satisfaction with the quality of services provided, particularly in the private healthcare system, and special attention must be paid to reliability in both healthcare systems. The identification and monitoring of the quality of healthcare services through the periodic use of the SERVQUAL scale may provide healthcare managers with information so that they can identify, plan, and monitor necessary and priority measures. This could be a key strategy for improving the quality of outpatient health services in the public and private systems.

RESUMO Objetivo: Comparar a percepção da qualidade dos serviços oftalmológicos prestado aos pacientes ambulatoriais do sistema público com a do sistema privado e detectar quais ações são percebidas como necessárias e prioritárias para melhorar a qualidade do atendimento. Métodos: Foi realizado estudo prospectivo observacional de 200 pacientes sendo 101 do sistema público de saúde e 99 do sistema privado submetidos a exame oftalmológico em Hospital Especializado em Oftalmologia (HEO) - Belo Horizonte - MG - Brasil. Realizaram-se entrevistas pessoais, mediante a aplicação de dois questionários estruturados adaptados da escala SERVQUAL modificada. Resultados: No geral, detectou-se que pacientes do sistema de saúde privado, estão significativamente mais insatisfeitos que aqueles do sistema público de saúde. Em ambos os sistemas a confiabilidade foi considerada o determinante de qualidade mais importante e o que apresentou o maior índice de insatisfação. No sistema público a satisfação foi significativamente superior à do sistema privado a nível dos determinantes da escala SERVQUAL: tangibilidade, confiabilidade, atendimento e segurança. Conclusões: A instituição deve planejar, executar, avaliar e monitorar ações que busquem melhorar a satisfação geral dos pacientes com a qualidade do serviço recebido, principalmente do sistema privado, com atenção especial à confiabilidade nos dois sistemas. A identificação e monitorização da qualidade dos serviços de saúde, empregando periodicamente a escala SERVQUAL, poderá fornecer informações à administração dos serviços de saúde para que possam detectar, planejar e monitorizar as ações necessárias e prioritárias, podendo funcionar como chave estratégica para o aprimoramento da qualidade dos serviços de saúde ambulatoriais públicos e privados.

Las nuevas escuelas de medicina en el panorama médico actual / The new medical schools in Chile and their influence on the medical scenario

There is concern about the possible consequences caused by the proliferation of private Medical Schools in Chile. Most of these schools have consolidated as health professional training centers, but its presence is changing the scenario of public health and medical profession. The most important consequence is the increase in the number of physicians that will occur, that may exceed the demand of the Chilean population and generate medical unemployment or emigration. There is also concern about the quality of the training process and the preparation and experience of teachers, that derives in the need for accreditation of medical schools. Private Universities are aware of these problems and are working on them. The struggle for clinical fields in the Public Health System has been regulated by an administrative norm of the Ministry of Health.

Controle glicêmico de pacientes diabéticos tipo 2 nos serviços público e privado de Saúde / Glycemic control in type 2 diabetic patients in public and private Healthcare service

OBJETIVO: Comparar o tratamento de pacientes diabéticos tipo 2 provenientes de uma clínica privada aos pacientes atendidos no sistema público de Saúde. MÉTODOS: Foi desenhado um estudo de coorte retrospectivo, incluindo 80 pacientes atendidos no Ambulatório Central da Universidade de Caxias do Sul (AMCE), vinculado ao Sistema Único de Saúde, e 277 pacientes atendidos em uma clínica privada, que foram consultados nestes serviços no período entre maio de 2001 e outubro de 2007. RESULTADOS: Os pacientes atendidos no AMCE mostraram pior controle metabólico, embora somente os valores de A1c e colesterol total tenham alcançado significância estatística. Ambos os grupos apresentaram melhora de quase todos os parâmetros metabólicos. O uso de insulina no final do acompanhamento (B = 4,66; IC95 por cento = 2,18 - 9,89; p < 0,001) e a A1c inicial (B = 1,42; IC95 por cento = 1,16 - 1,74; p = 0,001) foram determinantes de pior controle glicêmico. A frequência de consultas foi determinante de melhor controle (B = 0,72; IC95 por cento = 0,55 - 0,93; p = 0,01). CONCLUSÕES: As variáveis como a A1c inicial e a frequência de consultas, que podem ser consideradas como indicadores do acesso dos pacientes ao sistema de saúde, têm maior impacto no controle do diabetes do que o local no qual os pacientes são tratados.

OBJECTIVE: To compare the treatment of type 2 diabetic patients from a private clinic with those of a public health service. METHODS: It was designed a retrospective cohort study, including 80 patients attended at the Central Clinic of Universidade de Caxias do Sul (AMCE), which is related to the Single Health System, and 277 patients attended at a private clinic, whom consult between May 2001 and October 2007. RESULTS: Patients attended at AMCE showed a worse metabolic control, although only the values of A1c and total cholesterol have reached statistical significance. Both groups had an improvement in almost all the metabolic parameters. The use of insulin at the end of follow-up (B = 4,66; CI95 percent = 2,18 - 9,89; p < 0,001) and initial A1c (B = 1,42; CI95 percent = 1,16 - 1,74; p = 0,001) were determinant of a worse glycemic control. The frequency of visits was determinant of a better control (B = 0,72; CI 95 percent = 0,55 - 0,93; p = 0,01). CONCLUSIONS: The variables such as the initial A1c and the frequency of visits, which may be considered as indicators of patients' access to the heath system, have greater impact on the control of diabetes than the place where the patients are treated.

Adolescent pregnancy: a comparative study between mothers who use public and private health systems

This is a comparative and descriptive study of adolescent mothers who were attended in three maternities of the public health system and three private maternities in a city in São Paulo, Brazil, between 2000 and 2002. This study aimed to compare the profile of mothers attended in both systems. The database of Ribeirão Preto was used and 5,286 adolescent mothers between 10 and 19 years old were selected according to type of delivery, level of instruction, number of prenatal consultations and parity. We found that the users of the public health system had less prenatal consultations, lower level of education, higher parity and the vaginal delivery was most frequent. The users of the private health system, on the contrary, had more prenatal consultations, higher level of instruction, and primiparity and cesarean sections were more frequent.

Trata-se de estudo descritivo e comparativo entre mães adolescentes de nascidos vivos, atendidas em três maternidades do sistema público e três do privado de um município do Estado de São Paulo, Brasil. Teve como objetivo identificar e comparar o perfil das mães adolescentes atendidas nesses sistemas de saúde. Para a coleta de dados, utilizou-se o banco de dados da prefeitura de Ribeirão Preto, SP, de onde que foram selecionadas 5.286 adolescentes de 10 a 19 anos, segundo tipo de parto, grau de instrução, número de consultas de pré-natal e número de partos anteriores. Encontrou-se que as usuárias do sistema público fizeram menor número de consultas de pré-natal, possuíam menor escolaridade, tinham maior paridade, o parto normal foi mais freqüente, enquanto no privado foi maior o número de atendimento de pré-natal, a escolaridade, a primiparidade e o parto cesariano.

Se trata de un estudio descriptivo y comparativo entre madres adolescentes de nacidos vivos atendidas en tres maternidades del sistema público y tres del privado de una ciudad del estado de São Paulo, Brasil, entre 2000 y 2002. Su objetivo fue identificar y comparar el perfil de las madres adolescentes atendidas en los dos sistemas de salud. Para la recolecta de datos, se utilizó el banco de datos del gobierno municipal de Ribeirão Preto, de donde fueran seleccionadas 5.286 adolescentes entre 10 y 19 años según el tipo de parto, grado de instrucción, número de consultas de prenatal y número de partos anteriores. Se descubrió que las usuarias del sistema público hicieron menor número de consultas de prenatal, poseían escolaridad más baja, tenían mayor paridad, y que el parto normal fue más frecuente. En el privado, fue mayor el número de postventa de prenatal, la escolaridad, la primiparidad y el parto cesárea.

Screening for HIV infection by health professionals in India.

BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Case detection rate targets under DOTS: the Indian experience.

The DOTS programme in India has been recognized as the fastest growing programme in the world. It currently covers more than 1 billion people (90% of the population). In spite of this rapid expansion, the programme has consistently achieved the global target of 85% cure rates. However, improvement in case detection rates has been slow, and the global target of 70% has been achieved only in the last few quarters. Public-private partnerships were initiated at the national and local level with the non-health public sector, corporate sector and non-governmental organizations, private practitioners and medical colleges. The partnerships have significantly contributed to the case detection rates in the country, especially the medical colleges, which have contributed up to 5%-15%. Some areas achieved case detection rates well above 70%. There is a need to forge new initiatives, strengthen existing partnerships and make special efforts to access the poorer, vulnerable and hard-to-reach sections of society more effectively. This would not only increase the numbers of cases but also serve the overarching objective of equity. Disaggregated targets should be set, with much higher ones for selected areas, sectors and institutions.

Evolución de las universidades chilenas 1981-2004 / The evolution of Chilean universities from 1981 to 2004

In 1981, a supreme decree allowed the creation of private universities in Chile. As a consequence, 50 new universities were created in one decade, under the surveillance of the Council for Superior Education. This paper analyzes the evolution of this expansion process, that resulted in an admission of 370,000 students to 60 universities along the country, during 2004. At the moment, 42% of the universities, designed as traditional, receive state financing and 58% are private. Twenty six percent are owned by the state, 52% are secular and 22% are confessional. The 25 traditional universities are complex organizations of a high academic level. New private universities are only devoted to teaching and some have obtained their autonomy. Some have improved the quality of their academic staff, perform research and impart doctorate degrees. However, most are small and with a limited academic staff. Traditional universities are stratified in a superior level. Eight private universities and some regional institutions, that are becoming complex and performing research activities, are stratified in a middle level. Two thirds of the private universities are in the lower level. The expansion of superior education is a sign of the social and cultural progress that Chile has experienced.

Examining health equity through satisfaction and confidence of patients in primary healthcare in the Republic of Trinidad and Tobago.

Surveys of patient satisfaction are widely used for identifying priorities and problems in healthcare reforms. The present study examined satisfaction and confidence of patients in public healthcare in Trinidad and Tobago. Data were gathered by interviewing a random sample (n = 280) of primary healthcare (PHC) patients. Level of patient satisfaction was high but not constant. Results of interviews showed that patients with a higher monthly income (p = 0.032) and patients who most recently used private medical care (p = 0.037) had lower levels of satisfaction with health services. Employment had an effect on satisfaction (p = 0.065), significant among patients who had recently accessed private medical care (p = 0.039). Patients using PHC clinics preferred private care to public care. Confidence in public care decreased with increasing complexity of the medical condition. These preliminary results support continued efforts in health-sector reforms and call for the enhancement of data on satisfaction through more comprehensive qualitative data-collection methods.

Adherence of the private sector to national tuberculosis guidelines in the Islamic Republic of Iran, 2001-02

We determined the knowledge and practice of private sector physicians in three cites regarding management of pulmonary tuberculosis [TB] and their determinants. A random sample questionnaire survey was conducted of 732 private physicians. Stratified analysis and logistic regression were used to identify the adjusted determinants of the two outcomes. A high proportion of the doctors had correct knowledge about the major diagnostic criteria but there was a low level of knowledge and practice of TB management. Significant risk factors for poor knowledge were age > / = 36 years, being a GP rather than a specialist and no attendance in TB training courses or attendance in courses held by institutions other than the public health system. Age > / = 36 years was the only significant risk factor for poor practice

Avaliaçäo de agências reguladores: uma agenda de desafios para a sociedade brasileira / Evaluating regulatory agencies: an agenda of challenges for the Brazilian society

Trata do desenvolvimento de práticas de avaliação de agências reguladoras abertas à participação dos diferentes públicos afetados, que estimulem a transparência do processo decisório e não inibam a participação de setores privados na oferta de serviços de relevância social. Aprecia as dimensões relevantes da avaliação à luz de contribuições selecionadas na literatura estrangeira. Identifica desafios a serem enfrentados pelas agências e pela sociedade brasileira.

study of maternal and child health care services in private sector in urban Asir region

The differences in the maternal and child health care services offered by government and private sector in Abha and Khamis Mushayt cities in Asir Region of Saudi Arabia were compared. Self administered questionnaires and observation sheet were used for the study. It was found that the government clinics were more involved in the running of under 5 clinics and giving health education to patients. The private clinics took more care of women general health care but lacked the continuous domiciliary visit to pregnant women. The catchment area which served the government PHCCs made accessibility to service easier to government patients and this was thought to be the reason why government patients kept regular appointments. On the other hand, private patients who have the freedom to choose where they get service have been found to be irregular in keeping clinic appointment. It was suggested that there should be geographical spread in the location of private clinics to facilitate accessibility and that the health education and under 5 clinics should be well incorporated into the services offered by private clinics