Análise dos modelos de pagamento aplicados ao financiamento federal na perspectiva do Sistema Único de Saúde / Analysis of payment models applied to federal funding from the perspective of the Brazilian Health System

Objetivo: Este estudo tem por objetivo identificar os modelos de pagamento existentes no Sistema Único de Saúde referentes aos repasses federais para a Atenção Primária à Saúde (APS) e a Atenção Especializada à Saúde. Métodos: Foi realizado um estudo quantitativo e analítico, desenvolvido em três etapas: levantamento de todos os tipos de repasse da União; classificação de cada categoria de repasse segundo os tipos de modelos de pagamentos; e mensuração da participação de cada modelo de pagamento, de acordo com os componentes de financiamento analisados, em relação aos valores líquidos repassados. Resultados: Os repasses federais foram classificados em sete modelos de pagamentos. Para a APS, em 2020, foram apurados R$ 21,7 bilhões, aproximadamente, incluindo os recursos destinados para a pandemia, e R$ 20,9 bilhões, sem considerar os recursos para enfrentamento da pandemia de COVID-19. Mais de 50% dos valores empregados foram classificados como capitação, em ambos os casos. Para a Atenção Especializada à Saúde, em 2019, foram computados em torno de R$ 48,5 bilhões e, em 2020, acima de R$ 49,2 bilhões. Para os dois anos, mais de 70% dos recursos foram destinados a pagamentos por procedimento. Conclusões: Este estudo permitiu a ampliação do conhecimento sobre a alocação dos recursos referentes aos repasses da União para estados, Distrito Federal e municípios. Como os modelos de pagamentos estão relacionados com a produtividade, acesso e qualidade do serviço de saúde, conhecer as formas de pagamento e identificar a mais adequada para cada situação contribui para o alcance das metas e para a mitigação de eventuais perdas de eficiência nos sistemas de saúde.

Objective: This study aims at identifying the payment methods existing in the Unified Health System referring to federal transfers to Primary Health Care (PHC) and Specialized Health Care. Methods: A quantitative and analytical study was carried out, developed in three stages: survey of all types of transfers from the Union; classification of each transfer category according to the types of payment methods and measurement of the participation of each payment methods, according to the financing components analyzed, in relation to the net values transferred. Results: Federal transfers were classified into seven payment methods. For PHC, in 2020, approximately R$ 21.7 billion was calculated, including resources destined for the pandemic, and R$ 20.9 billion without considering resources to face the COVID-19 pandemic. More than 50% of the amounts used were classified as capitation, in both cases. For specialized health care, in 2019, around R$ 48.5 billion were calculated, and in 2020 more than R$ 49.2 billion. For the two years, more than 70% of the funds were allocated to fee for service. Conclusions: This study allowed for an expansion in knowledge about the allocation of resources referring to transfers from the Union to states, the Federal District and municipalities. As the payment methods are related to productivity, access and quality of the health service, knowing and identifying the most appropriate payment methods for each situation contributes to the achievement of the goals and to the mitigation of eventual losses of efficiency in the healthcare systems.

Oportunidades e desafios da saúde baseada em valor: como o Brasil pode aprender com a experiência dos Estados Unidos / Opportunities and challenges of value-based healthcare: how Brazil can learn from the United States' experience

O movimento em direção à saúde baseada em valor é uma evolução que ocorre em muitas nações do mundo. O crescimento populacional, o aumento da expectativa de vida e o custo crescente com uma saúde de alta tecnologia exigem que os pagadores públicos e privados de todo o mundo criem novas maneiras de garantir que os gastos com saúde sejam feitos nas intervenções de maior impacto. Nesse ponto de vista, apresentamos o caso da transformação da saúde baseada em valor, que está atualmente em sua infância no Brasil. O Brasil possui pagadores públicos e privados e ainda paga os serviços na maioria das vezes no modelo de pagamento por procedimento. Comparamos isso com a experiência recente nos Estados Unidos, onde a saúde baseada em valor está, de maneira lenta, mas segura, se tornando a norma. O Sistema de Saúde Brasileiro tem muitas oportunidades de aprender com a mudança ocorrida nos EUA para um modelo de saúde baseado em valor ­ incluindo o desenvolvimento de medidas de qualidade, a transição para pagamento baseado em valor e a melhoria dos dados para avaliar o desempenho nos sistemas de saúde brasileiros. As indústrias de produtos farmacêuticos no Brasil também podem desempenhar um papel, com acordos baseados em valor e parcerias com pagadores. Cada nação seguirá seu próprio caminho para uma saúde baseada em valor, mas a oportunidade de aprender um com o outro possibilita melhores chances de sucesso.

The movement toward value-based care is an evolution occurring in many nations of the world. The increasing population, longer life expectancy, and rising cost for high-tech care necessitates that government and private payers around the world devise new ways to ensure that healthcare dollars are spent on the most impactful interventions. In this viewpoint, we present the case of the value-based care transformation that is currently in its infancy in Brazil. Brazil has a mix of private and public payers but still largely reimburses based on a fee-for-service model. We contrast that with recent experience in the United States, where value-based care is slowly but surely becoming the norm. The Brazilian system has many opportunities to learn from the US shift to value-based care ­ including the development of quality measures, transition to value-based payment, and leveraging data to rank performance across Brazilian health systems. Pharmaceutical manufacturers in Brazil can play a role as well, with value-based agreements and partnerships with payers. Each nation will travel on its own path to value-based healthcare, but the opportunity to learn from each other presents one of the best chances for success.

Estudo prospectivo para validação de protocolo único para o teste respiratório com ureia marcada com carbono-13 empregando dois dispositivos diferentes, no diagnóstico da infecção por H. pylori / Prospective study for validation of a single protocol for the 13c-urea breath test using two different devices in the diagnosis of h. pylori infection

ABSTRACT BACKGROUND: 13C-urea breath test (UBT) is the gold-standard, noninvasive method for H. pylori diagnosis. However, there is no uniform standardization of the test. This situation can be unpractical for laboratories running with two or more devices. OBJECTIVE: To perform a prospective comparison validation study of UBT employing one validated protocol for two different devices: BreathID Hp Lab System® (Exalenz Bioscience Ltd, Israel), here called device A and IRIS-Doc2® (Wagner Analysen-Technik, Germany, now Mayoly Spindler Group, France), here called device B, in the diagnosis of H. pylori infection. METHODS: A total of 518 consecutive patients (365 females, 153 males, mean age 53 years) referred for UBT were included. All patients received device A protocol as follow: after at least one hour fasting, patients filled two bags prior to the test, then ingested an aqueous solution containing 75 mg of 13C-urea with a 4.0 g citric acid powder and filled another two bags 15 min after ingesting the test solution. One pair of breath sample bags (before and after ingestion) was analyzed by the two different devices. A delta over baseline (DOB) ≥5‰ indicated H. pylori infection. Statistics: Wilcoxon test, kappa coefficient with 95% CI, Wilson's method. RESULTS: Considering the device A protocol as the gold standard, its comparison with device B showed a sensitivity of 99.3% (95% CI: 96.3-99.9) and a specificity of 98.9% (95% CI: 97.3-99.6). Kappa coefficient was 0.976 (95% IC: 0.956-0.997). CONCLUSION: Correlation between the two devices was excellent and supports a uniform standardization of UBT.

RESUMO CONTEXTO: O teste respiratório com ureia-marcada com carbono-13 (TR-13C) é o método padrão-ouro para o diagnóstico não invasivo da infecção por H. pylori. Apesar disto, não existe uma uniformização de protocolos para a sua realização, trazendo dificuldades operacionais para laboratórios ou clínicas que operam com equipamentos de fabricantes diferentes. OBJETIVO: Estudo prospectivo e comparativo para validação do TR-13C para o diagnóstico de infecção por H. pylori, com emprego de protocolo único para dois equipamentos diferentes, a saber: BreathID Hp Lab System® (Exalenz Bioscience Ltd, Israel), aqui denominado equipamento A e IRIS-Doc2® (Wagner Analysen-Technik, Alemanha, agora Mayoly Spindler Group, França), aqui denominado equipamento B. MÉTODOS: Um total de 518 pacientes (365 mulheres e 153 homens, idade média de 53 anos) consecutivamente encaminhados para a realização do TR-13C foram incluídos no estudo. Todos os participantes realizaram TR-13C, que foi processado e analisado simultaneamente pelos dois equipamentos. Embora os dois equipamentos possuam protocolos independentes previamente validados, foi optado, por sua maior praticidade, pela utilização de um único protocolo, conforme recomendado pelo fabricante do equipamento A, e assim resumido: após jejum mínimo de 1h, foram amostras de ar expirado coletadas em dois pequenos sacos coletores (120 mL), correspondendo ao tempo-zero (amostra-1, controle). Em seguida, os pacientes ingeriram, em até 2 min, uma solução aquosa (200 mL) contendo 75 mg de 13C-ureia e 4,0 gramas de ácido cítrico em pó, adicionado com edulcorante. Uma segunda coleta de ar expirado era realizada 15 min após a ingestão do substrato em dois novos pequenos sacos coletores, correspondendo à amostra-2. Foram considerados positivos para a presença da infecção por H. pylori quando apresentavam um delta over baseline (DOB) igual ou maior que 5‰. Análise estatística foi realizada com o teste de Wilcoxon, coeficiente kappa com IC 95% e método de Wilson. RESULTADOS: Considerando o protocolo do equipamento A como o padrão-ouro, sua comparação com o equipamento B mostrou sensibilidade de 99,3% (IC 95%: 96,3-99,9) e especificidade de 98,9% (IC 95%: 97,3-99,6). O coeficiente kappa observado foi de 0,976 (IC 95%: 0,956-0,997). CONCLUSÃO: A correlação entre os dois equipamentos foi excelente e contribui para uma uniformização de protocolos para TR-13C.

The Effect of Diagnosis-Related Group Payment System on Quality of Care in the Field of Obstetrics and Gynecology among Korean Tertiary Hospitals

PURPOSE: To examine changes in clinical practice patterns following the introduction of diagnosis-related groups (DRGs) under the fee-for-service payment system in July 2013 among Korean tertiary hospitals and to evaluate its effect on the quality of hospital care. MATERIALS AND METHODS: Using the 2012–2014 administrative database from National Health Insurance Service claim data, we reviewed medical information for 160400 patients who underwent cesarean sections (C-secs), hysterectomies, or adnexectomies at 43 tertiary hospitals. We compared changes in several variables, including length of stay, spillover, readmission rate, and the number of simultaneous and emergency operations, from before to after introduction of the DRGs. RESULTS: DRGs significantly reduced the length of stay of patients undergoing C-secs, hysterectomies, and adnexectomies (8.0±6.9 vs. 6.0±2.3 days, 7.4±3.5 vs. 6.4±2.7 days, 6.3±3.6 vs. 6.2±4.0 days, respectively, all p < 0.001). Readmission rates decreased after introduction of DRGs (2.13% vs. 1.19% for C-secs, 4.51% vs. 3.05% for hysterectomies, 4.77% vs. 2.65% for adnexectomies, all p < 0.001). Spillover rates did not change. Simultaneous surgeries, such as colpopexy and transobturator-tape procedures, during hysterectomies decreased, while colporrhaphy during hysterectomies and adnexectomies or myomectomies during C-secs did not change. The number of emergency operations for hysterectomies and adnexectomies decreased. CONCLUSION: Implementation of DRGs in the field of obstetrics and gynecology among Korean tertiary hospitals led to reductions in the length of stay without increasing outpatient visits and readmission rates. The number of simultaneous surgeries requiring expensive operative instruments and emergency operations decreased after introduction of the DRGs.

Remuneración a los proveedores de servicios de salud en Bogotá / Payment to providers of health services in Bogotá

RESUMEN Objetivo Revisar los conceptos, desarrollos y efectos de los mecanismos de pago utilizados en diversos países, con el fin de proponer una metodología de pago aplicable para los hospitales de Bogotá. Método Se efectuó una revisión bibliográfica de tres aspectos de interés: conceptos esenciales, desarrollos alcanzados y efectos derivados de los mecanismos de pago utilizados en diversos países. Luego se efectuaron sesiones de trabajo entre los autores y con diversos grupos y equipos de la secretaria de salud de Bogotá, los hospitales, la academia y las autoridades nacionales en salud, para el diseño metodológico de un esquema de pago aplicable a los hospitales de la red adscrita de salud en Bogotá. Resultados La revisión bibliográfica permitió establecer los ejes de trabajo para un esquema de pago prospectivo por red con incentivos de desempeño, basado en optimización de la eficiencia técnica (provisión de servicios de salud a menor costo) y locativa (optimización de la mezcla de los servicios de salud) y en mejores resultados de atención. Discusión El esquema de reconocimiento planteado debe ser un factor integrador del proceso de atención al paciente y redundar en una mejor operación del aseguramiento, la prestación de servicios y la gobernanza de la atención en salud, al tiempo que optimiza el flujo de recursos y la sostenibilidad local del sistema.(AU)

ABSTRACT Objective To review the concepts, developments and effects of the payment mechanisms used in different countries to propose a payment methodology applicable to hospitals in Bogotá. Method Literature review in which essential concepts, developments and effects derived from payment mechanisms used in different countries were analyzed. The authors and various groups and teams of the Bogotá Health Department participated, hospitals, academia and national health authorities held work sessions with the intention of creating a methodological design for a payment scheme that could be applied to the hospitals attached to the health network in Bogotá. Results The literature review allowed establishing work axes for a prospective payment scheme per network that included performance bonuses based on the optimization of technical efficiency (provision of health services at lower cost, locative efficiency (optimization of the mix of health services), and on better care outcomes. Discussion The proposed payment scheme should be an integrating factor in the patient care process, and should also result in a better operation, service delivery and health care governance, while optimizing the flow of resources and local sustainability.(AU)

Early outcome of the Korean Diagnosis-Related Groups payment system for appendectomy

PURPOSE: The implementation of the Korean diagnosis-related groups (DRG) payment system has been recently introduced in selected several diseases including appendectomy in Korea. Here, we report the early outcomes with regard to clinical aspects and medical costs of the Korean DRG system for appendectomies in Seoul Metropolitan Government - Seoul National University Boramae Medical Center throughout comparing before and after introduction of DRG system. METHODS: The DRG system was applied since January 2013 at our institute. After the DRG system, we strategically designed and applied our algorithm for the treatment of probable appendicitis. We reviewed the patients who were treated with a procedure of appendectomy for probable appendicitis between July 2012 and June 2013, divided two groups based on before and after the application of DRG system, and compared clinical outcomes and medical costs. RESULTS: Total 416 patients were included (204 patients vs. 212 patients in the group before vs. after DRG). Shorter hospital stays (2.98 +/- 1.77 days vs. 3.82 +/- 1.84 days, P < 0.001) were found in the group after DRG. Otherwise, there were no significant differences in the perioperative outcomes and medical costs including costs for first hospitalization and operation, costs for follow-up after discharge, frequency of visits of out-patient's clinic or Emergency Department or rehospitalization. CONCLUSION: In the Korean DRG system for appendectomy, there were no significant differences in perioperative outcomes and medical costs, except shorter hospital stay. Further studies should be continued to evaluate the current Korean DRG system for appendectomy and further modifications and supplementations are needed in the future.

Refinement and Evaluation of Korean Outpatient Groups for Visits with Multiple Procedures and Chemotherapy, and Medical Visit Indicators / 보건행정학회지

BACKGROUND: Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement. METHODS: We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation. RESULTS: EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics. CONCLUSION: A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.

[ comparison of the cost of patient records in a global system with corresponding retrospective reimbursement system: a case study in Iran]

Introduction: The reimbursement mechanism of the cost of treatment is an important factor which directly or indirectly affects the financial management and control of hospitals costs, hence different countries use different reimbursement systems. This study evaluated the prospective reimbursement system [global system]; at one of the hospitals in Hormozgan University of Medical Sciences

Methods: This descriptive-analytical study evaluated 1286 Global inpatient records in Fekri hospital affiliated to Hormozgan University of Medical Sciences. First the actual cost of care and length of stay for each of the global records was extracted using the hospital information system. Then the average cost and patient's stay for each of global procedures were compared with the cost and length of stay determined by Iran global system. Data analysis was performed using descriptive statistics and T-test was used to test the research questions

Results: One quarter of all inpatient records belonged to global payment system. 62% of global records belonged to OB/GY operations, 20% to general surgery and 18% to ophthalmic surgery. The analysis of the cost of 86% of surgery global records showed to be beneficial for the hospital, where 91% of these cost differences were found to be significant. For more than 99% of cases in global system, the average length of stay was less than average standard length of stay, and for 64% cases this difference was found to be statistically significant

Conclusion: Regarding the reduction of length of stay of patients in global payment system, the review and implementation of global payment system for other diagnoses and operations is highly recommended

Mercado y consumo de cigarrillos en Cuba y la decisión entre tabaco o salud / Market for and consumption of cigarettes in Cuba and the choice between tobacco and health

Introducción: caracterizar mediante estudios de mercado el consumo de cigarrillos y su relación con precio y formas de comercialización, aporta elementos necesarios para fundamentar propuestas de políticas públicas que tributen a la reducción del tabaquismo y al bienestar de la población. Objetivos: describir el consumo de cigarrillos en el 2013 en relación con el del 2012, su correspondencia con precio y formas de comercialización así como caracterizar el mercado de cigarrillos y su segmentación. Métodos: estudio observacional descriptivo, con datos agregados de series temporales. Resultados: el consumo per cápita de cigarrillos en 2013 en relación con el del 2012 creció 4,8 por ciento, el precio promedio se incrementó 1,7 por ciento derivado del aumento de las ventas en pesos cubanos convertibles, aunque sin impacto en el consumo; el mercado en pesos cubanos, siguió siendo el preferido para la adquisición de cigarrillos por la población cubana y la marca Criollo fue la más solicitada. Conclusiones: el aumento en el consumo de cigarrillos en el 2013 en comparación con el 2012 pudiera tomarse como el inicio de una nueva tendencia creciente, donde se mantiene la preferencia por el mercado en pesos cubanos. No incrementar los precios en proporciones que regulen la demanda, unido al crecimiento de los ingresos en algunos segmentos de la población, constituyen factores económicos favorecedores al consumo por la población cubana. La segmentación del mercado ofrece los argumentos para la elaboración de una estrategia de reducción de la demanda(AU)

Introduction: the market study-based characterization of cigarette consumption and its relationship with prices and ways of marketing may provide necessary elements to support the public policies for the reduction of smoking and the improved wellbeing of the population. Objectives: to describe the consumption of cigarettes in 2013 in comparison with that of 2012, its relationship with prices and ways of marketing and to characterize the cigarette market and segmentation. Methods: observational and descriptive study using time series aggregate data. Results: the per capita cigarette consumption in 2013 increased by 4.8 percent if compared with that of 2012; the average price grew by 1.7 percent resulting from higher sales in Cuban convertible pesos with no significant impact on the consumption; the cigarette market in Cuban pesos remains the first choice for the Cuban population whereas Criollo brand is the most requested. Conclusions: the rise of cigarette consumption in 2013 after a comparison with that of 2012 may be considered as the starting of a new growing tendency that keeps the choice of purchasing cigarettes with the national currency. The increase of prices in such amounts that do not control demand and the rise of the incomes of some Cuban population segments are encouraging economic factors for smoking. The market segmentation provides the required arguments for drawing up a cigarette demand-reducing strategy(AU)

Efectos de las políticas sanitarias sobre la contención del gasto sanitario en Chile / Influence of sanitary policies on health care cost containment in Chile

Introducción: La literatura económica propone diversos mecanismos de pago a proveedores, con el objetivo de conseguir incentivos en la contención del gasto sanitario. Objetivos: Analizar los fundamentos teóricos y efectividad de los instrumentos de pago, pago asociado a diagnóstico (PAD) y pago por prestaciones valoras (PPV), en la contención de costos implementados en Chile a lo largo de los últimas dos décadas, y evaluar cuantitativamente los efectos que han tenido dichos mecanismos de pago prospectivos recientemente creados sobre la utilización de los servicios hospitalarios de la Región Metropolitana (RM) y demás regiones del país. Diseño: Análisis econométrico y no paramétrico. Lugar: Chile. Materiales: Se utilizó datos del Ministerio de Salud de Chile (MINSAL) y del Fondo Nacional de salud (FONASA). Intervenciones: Aplicación de la metodología de series temporales, análisis envolvente de datos y modelo lógit multinomial para detectar si los mecanismos de pago han tenido el efecto deseado en la contención de costos. Principales medidas de resultados: Efectos de los mecanismos de pago a hospitales. Resultados: Los resultados han puesto de manifiesto que el segundo mecanismo de pago introducido, además de no generar incentivos en la reducción de las estancias promedio a nivel nacional tampoco ha generado niveles de eficiencia mas altos. Conclusiones: El primer mecanismo de pago PAD tiene un efecto positivo en la contención del uso de recurso. Por otro parte, en el segundo mecanismo de pago PPV no solo se utiliza más recursos, sino que además es posible que el sistema esté actuando de forma perversa dificultando la adopción de medidas que favorezcan la eficiencia.

Introduction: The literature on economics proposes different provider payment mechanisms at hospitals in order to obtain incentives in health care cost containment. Objectives: To analyze the theoretical foundations of implemented cost restraint instruments, payment associated to diagnosis (PAD), and payment for valued assistance (PFV) during the last two decades and their effectiveness on the Chilean sanitary system. Design: Econometric and non parametric analysis. Setting: Chile. Materials: Data from ChileÆs Ministry of Health and the National Health Fund was used. Interventions: Application of time series methodology, data envelopment analysis and multinomial logit model to detect whether payment mechanisms have had the desired effect on cost containment. Main outcome measures: Effects of hospital payment system. Results: Results have shown that the second payment system, in addition to not creating incentives in average stays reduction nationally it has neither generated higher levels of efficiency. Conclusions: The first payment system had a positive effect in curbing resources use. The second mechanism of payment generated neither incentives in the reduction of average stay in the country nor higher levels of efficiency. That is to say, not only more resources are used but also it is possible that the system is acting in a wicked way making difficult to take measures that favors efficiency.

[Challenges of determining basic health insurance package in Iran]

To assess challenges of determining basic health insurance package in Iran. We interviewed a purposeful sample of 20 participants from 7 main stakeholders in Iranian health insurance system in 2009. We asked about main challenges of determining basic health insurance package in Iran and used the framework method for the analysis. Agreement on General Principle, determining Criteria to define Basic Health Insurance Package, Organization, Financing, Payment System, Regulations, Benefits range, Composition and manner of population coverage, Coordination, Behavior, Policy Making, Surveillance and Control had been introduced as main Challenges of Determining Basic Health Insurance Package in Iran. Determining an appropriate health insurance package in Iran needs a systematic view and a long term plan. The plan should aim to respond to the above concerns

Participation Determinants in the DRG Payment System of Obstetrics and Gynecology Clinics in South Korea / 예방의학회지

OBJECTIVES: The Diagnosis Related Group (DRG) payment system, which has been implemented in Korea since 1997, is based on voluntary participation. Hence, the positive impact of this system depends on the participation of physicians. This study examined the factors determining participation of Korean obstetrics & gynecology (OBGYN) clinics in the DRG-based payment system. METHODS: The demographic information, practice-related variables of OBGYN clinics and participation information in the DRG-based payment system were acquired from the nationwide data from 2002 to 2007 produced by the National Health Insurance Corporation and the Health Insurance Review & Assessment Service. The subjects were 336 OBGYN clinics consisting of 43 DRG clinics that had maintained their participation in 2003-2007 and 293 no-DRG (fee-for-service) clinics that had never been a DRG clinic during the same period. Logistic regression analysis was carried out to determine the factors associated with the participation of OBGYN clinics in the DRG-based payment system. RESULTS: The factors affecting participation of OBGYN clinics in the DRG-based payment system were as follows (p<0.05): (1) a larger number of caesarian section (c/sec) claims, (2) higher cost of a c/sec, (3) less variation in the price of a c/sec, (4) fewer days of admission for a c/sec, and (5) younger pregnant women undergoing a c/sec. CONCLUSIONS: These results suggest that OBGYN clinics with an economic practice pattern under a fee-for-service system are more likely to participate in the DRG-based payment system. Therefore, to ensure adequate participation of physicians, a payment system with a stronger financial incentive might be more suitable in Korea.

Una revisión de las formas de pago de los servicios de salud en el Distrito Capital / A review of the forms of payment for health services in the Capital District / A review of the forms of payment of the services of health in the Cardinal District

Este artículo es una presentación de la evaluación de las formas de pago a través de las cuales se reconocen los servicios prestados a la población pobre no afiliada en el Distrito Capital. Los resultados del presente trabajo se concentran principalmente en el análisis de una de las formas de pago, Pago Global Fijo prospectivo por actividad final, y tan sólo en dos de las actividades finales definidas por la Secretaría. Tales actividades son: la consulta de medicina general electiva y la consulta de medicina especializada electiva. Estas dos actividades representan, entre las dos, el 81,15% de las actividades finales realizadas por la red de hospitales y de ellas la atención médica general representa el 79,70%. El proceso metodológico para toda la evaluación desarrollo seis grande subprocesos: a) revisión bibliográfica, b) un marco conceptual y el diseño del plan de análisis, c) revisión de las especificaciones técnicas para la identificación de los registros de prestaciones de servicios de salud enviados, d) evaluación del sistema actual, e) construcción de escenarios de ajuste, y f) formulación de indicadores para el seguimiento de las formas de pago. A partir de los resultados se encontró que los actuales sistemas de pago del Fondo Financiero Distrital requiere ajustes que permitan un mejor manejo del riesgo financiero y la búsqueda de conciliación de los objetivos de política entre la Secretaría Distrital de Salud y los hospitales que prestan los servicios a la población pobre no cubierta con subsidios a demanda. Antes de pensar en migrar a otro sistema, se hace necesario entender que cada uno de los mecanismos genera diferentes incentivos los cuales se busca controlar a través del sistema de monitoreo y evaluación.

This article presents an evalution of the forms of pay that recognize services rendered to the poor population not housed in the capital district. The results of the present work are concentrated principlally in an analysis of one form of pay: Global fixed prospective pay for finished activities, and only in two of the finished activities as definined by the Secretary. Such work is: general elective medical consultations and specialized elective medical consultations and specialized elective medical consultation. These two activities represent, between the two, some 81.15% of the finished activites done by the network of hospitals, and of these the general medical attention represents 79.70%.This methodological process for a full evaluation creates six large subprocesses: a) bibliographic review, b) a conceptual framework and the design of a plan for analysis, c) review of the technical specifications for the identification of the registries for health services rendered, d) evaluation of the currents system, e) construction of adjustment scenarios, and f) formulation of indicators for the continuation of the forms of pay. From these results it was found that the current payment systems of the District Financial Fund require adjustments that permit better management of financial risk. The search must continue for the conciliationof political objectives between the District Health Secretary and the hospitals that serve the poor population not covered by necessary subsidies. Before thinking of moving to another system, it is necessary to understand that each one of the mechanisms generates different incentives which can be controled through the monitoring and evaluation systems.

Estimation of Nursing Costs by a Patient Classification System(PCS) in ICU / 간호학회지

PURPOSE: The objective of our study was to figure out costs of nursing services in ICU based on the PCS in order to determine an appropriate nursing fee schedule. METHOD: Data was collected from 2 hospitals from April 15-16 to April 22-23, 2003. The costs of nursing services in the ICU were analyzed by nursing time based on the nursing intensity. The inpatients in the ICU were classified by a PCS tool developed by the Korean Clinical Nurses Association(2000). RESULTS: The distribution of patients by PCS in the ICU ranged from class IV to Class VI. The higher PCS in ICU consumed more nursing time. As a result, the higher nursing intensity, the more the daily average nursing costs in the ICU. CONCLUSION: Our study provides evidence to refine the current nursing fee schedule that does not differentiate from the volume of nursing services based on nursing time. We strongly recommend that the current reimbursement system for nursing services should be applied not only to the general nursing units but also to the ICU or other special nursing units.

Aspectos neurologicos en niños con espectro autista. Estudio prospectivo de 100 casos / Neurological features of children with autistic spectrum disorders. A prospective study of 100 cases

Objetivo: Analizar en niños con síndrome del espectro autista aspectos clínicos, neurológicos y etiológicos, edad y motivo de la primera consulta a un médico, edad y motivo de consulta a nuestro servicio y comparar nuestros hallazgos con los ya reportados en la literatura. Métodos: En 100 niños afectados por un síndrome del espectro autista consignamos sus antecedentes pre, peri, postnatales y familiares, momento y motivo de la primera consulta a un profesional relacionada a su cuadro cognitivo, conductual o neurológico, edad y motivo de consulta a nuestro servicio, hallazgos clínicos, neurológicos, neurofisiológicos (EEG, PEAT), neurorradiológicos (TC/RM de cerebro), genéticos y neurometabólicos. La evaluación neuropsicológica se realizó en un doble contexto (natural y experimental), incluyendo técnicas formales e informales. Resultados: la relación varón /mujer fue 5,2/1, la edad media de nuesra población fue de 5 años y 7 meses. La edad media de la primera consulta a un profesional fue a los 20 meses y el motivo de la misma fue en un 24 por ciento trastorno en el desarrollo del lenguaje y conducta, 22 por ciento retraso en el desarrollo del lenguaje, 21 por ciento trastornos de conducta, 12 por ciento convulsiones y 4 por ciento otras causas. En el momento de nuestra consulta solo un 15 por ciento llegó con diagnóstico del espectro autista. Conclusiones: La relación varón mujer fue similar a la reportada por otros autores. Si bien la edad media de primera consulta también fue coincidente con otras publicaciones, el motivo de la misma como hemos observado, no fue solo el trastorno en el desarrollo del lenguaje sino un espectro más amplio. La prevalencia de RM fue del 95 por ciento, un 22 por ciento padeció epilepsia y en un 27 por ciento de los niños identificamos una entidad neurológica asociada siendo un 15 por ciento de base genética. Creemos importante jerarquizar la observación conductual y madurativa con el fin de reconocer tempranamente este síndrom...

On the Feasibility of a RUG-III based Payment System for Long-Term Care Facilities in Korea / 간호학회지

PURPOSE: The purpose of this study was to classify the elderly in long-term care facilities using the Resource Utilization Group(RUG-III) and to examine the feasibility of a payment method based on the RUG-III classification system in Korea. METHOD: This study measured resident characteristics using a Resident Assessment Instrument-Minimum Data Set(RAI-MDS) and staff time. Data was collected from 530 elderly residents over sixty, residing in long-term care facilities. Resource use for individual patients was measured by a wage-weighted sum of staff time and the total time spent with the patient by nurses, aides, and physiotherapists. RESULT: The subjects were classified into 4 groups out of 7 major groups. The group of Clinically Complex was the largest (46.3%), and then Reduced Physical Function(27.2%), Behavior Problems (17.0%), and Impaired Cognition (9.4%) followed. Homogeneity of the RUG-III groups was examined by total coefficient of variation of resource use. The results showed homogeneity of resource use within RUG-III groups. Also, the difference in resource use among RUG major groups was statistically significant (p<0.001), and it also showed a hierarchy pattern as resource use increases in the same RUG group with an increase of severity levels(ADL). CONCLUSION: The results of this study showed that the RUG-III classification system differentiates resources provided to elderly in long-term care facilities in Korea.

Evaluación del Sistema de Pago Implementado por la Secretaría Distrital de Salud de Bogotá D.C. en las ESE / Evaluation of the Payment System Implemented by the District Health Secretariat of Bogota D.C. in the ESE

Objetivo: el objetivo general del estudio es evaluar el impacto para el año 2000 en los aspectos financieros, de calidad de la atención, desenlace clínico e indicadores hospitalarios debido al cambio al sistema de pago fjo global prospectivo (SPFGP) implementado en las empresas sociales del Estado de nivel I, II y III de atención adscritas a la Secretaría Distrital de Salud (SDS) en 1999. Fuentes de información: se consultaron tres tipos de fuentes: como fuente primaria de datos se consultaron 2400 historias clínicas, de todos los hospitales de la red adscrita la SDS (29 antes de fusionar); como fuentes secundarias se consultó información financiera, epidemiológica y de producción de la SDS y algunos hospitales: también las bases de datos del trabajo de Fedesarrollo y de las interventoras de la SDS: como tercera fuente se realizaron entrevistas a los gerentes de los hospitales, a las coordinaciones de enfermería y a miembros de las juntas directivas de los hospitales. Diseño del estudio: se plantea un análisis económico, apoyado en entrevistas, sobre los efectos del cambio en el nesgo financiero efectuado por el cambio en el sistema de pago: dada la complejidad del estudio se establece un esquema para su análisis, así: i) todo sistema de pago transmite incentivos asociados a la unidad de pago y nesgo financiero que ocasionarán o no distintos comportamientos en los hospitales; ii) los comportamientos dependerán del grado de implantación óptima del sistema de pago, y iii) los efectos anteriores y su magnitud en la gestión, calidad y resultados clínicos están también influenciados por otras variables no asociadas al sistema de pago; se establecen varios modelos para la resolución, así: i) modelo de elección gerencial basado en una estructura de monopolio dual, para identificar los incentivos provenientes del SPFGP y acotar el alcance de su efecto: ii) modelo de optimización basado en utilidad esperada del beneficio para determinar los riesgos sobre los servicios del hospital, definidos como unidad productiva básica, y iii) modelos adicionales para normalización de gravedad e identificación de sus determinantes, modelo de localización de la demanda y la técnica de operaciones efectivas para los resultados financieros. Resultados principales: i) se presentan incrementos discretos en la productividad de los hospitales, con disminución de las actividades intermedias; ii) con la información disponible, el cambio de sistema de pago no tiene un efecto adicional sobre la estabilidad financiera a nivel agregado. La variable determinante de la estabilidad es el gasto; en tal sentido, el techo presupuestal se convierte en la mayor restricción; iii) no se presentan cambios significativos sobre la calidad, la satisfacción y los resultados clínicos. Se detectaron cambios significativos en las varianzas como producto del proceso de implantación. Conclusiones: i) un sistema de pago no puede analizarse de manera independiente del resto de políticas y mecanismos que tiene el financiador sobre el proveedor; en este sentido, el SPFGP es coherente con los objetivos sociales y técnicos propuestos en 1999; ii) las restricciones y distorsiones de incentivos en el financiamiento provienen principalmente de tres factores no controlables en el corto plazo: la no división neta de funciones de financiamiento y provisión; el sistema de información y sus algoritmos y, finalmente, la introducción de subsidios al gasto en el financiamiento de la mayoría de sistemas públicos; iii) las limitaciones de los efectos esperados del SPFGP sobre la eficiencia de gestión y la competitividad de los hospitales, en su mayoría, provienen del volumen del gasto fijo, de las restricciones de demanda para la venta a terceros (monopolios geográficos) y de problemas propios del diseño del SPFGP.

Objective: the general objective of the study is to evaluate the impact for the year 2000 on financial aspects, quality of care, clinical outcome, and hospital indicators due to the change to the global prospective fixed payment system (SPFGP) implemented in the State social enterprises of level I, II, and III of care assigned to the District Health Secretariat (SDS) in 1999. Sources of information: three types of sources were consulted: as a primary source of data, 2,400 medical records were consulted from all the hospitals in the network attached to the SDS (29 before the merger); as secondary sources, financial, epidemiological and production information from the SDS and some hospitals was consulted; also the databases of Fedesarrollo and the SDS auditors; as a third source, interviews were conducted with hospital managers, nursing coordinators and members of the hospital boards of directors. Study design: an economic analysis is proposed, supported by interviews, on the effects of the change in the financial risk caused by the change in the payment system: given the complexity of the study, a scheme for its analysis is established as follows: (i) every payment system conveys incentives associated with the unit of payment and financial nesgo that will or will not cause different behaviors in hospitals; (ii) behaviors will depend on the degree of optimal implementation of the payment system; and (iii) the above effects and their magnitude on management, quality and clinical outcomes are also influenced by other variables not associated with the payment system; several models are established for resolution, as follows: (i) managerial choice model based on a dual monopoly structure, to identify the incentives coming from the SPFGP and to narrow down the scope of its effect: (ii) optimization model based on expected utility of profit to determine the risks on hospital services, defined as a basic productive unit, and (iii) additional models for severity normalization and identification of its determinants, demand location model and the effective operations technique for financial results. Main results: i) there are discrete increases in hospital productivity, with a decrease in intermediate activities; ii) with the information available, the change in the payment system does not have an additional effect on financial stability at the aggregate level. The determining variable for stability is expenditure; in this sense, the budget ceiling becomes the greatest restriction; iii) there are no significant changes in quality, satisfaction and clinical outcomes. Significant changes were detected in the variances as a result of the implementation process. Conclusions: i) a payment system cannot be analyzed independently from the rest of the policies and mechanisms that the funder has over the provider; in this sense, the SPFGP is consistent with the social and technical objectives proposed in 1999; ii) the restrictions and incentive distortions in financing come mainly from three factors that are not controllable in the short term: the no net division of financing and provision functions; the information system and its algorithms and, finally, the introduction of spending subsidies in the financing of most public systems; iii) the limitations of the expected effects of the SPFGP on the management efficiency and competitiveness of hospitals, mostly stem from the volume of fixed spending, from demand restrictions for sales to third parties (geographic monopolies) and from problems inherent to the design of the SPFGP.

Reporte de diseño 2: Cálculo de tarifas de pago hospitalario y presupuestos. Pautas experimentales para el Perú / Design report 2: Stimates of the hospitalar payment fees and budgets. Experimental guidelines for Peru

Contiene: Reembolso de servicios de internamiento por casos; Reembolso de atención ambulatoria basada en servicios. Anexos: Cálculo de las tarifas de pago prospectivo para los hospitales y su ajuste según el volumen de servicios hospitalarios; Cálculo de los presupuestos y tarifas capitadas