Liberais de pacotilha (3)
... “Physician-owned hospitals are a problem because they are being overutilized,” Mr. Pallone said recently on the House floor. “Physicians are referring patients to these hospitals in many cases for unnecessary procedures.” link
The American Hospital Association, which represents 5,000 hospitals of all types, supports the proposal.
Doctor-owned hospitals “create a potential conflict of interest between a patient’s health care needs and the physician’s financial interests,” said Richard J. Pollack, executive vice president of the hospital association. Moreover, he said, doctor-owned specialty hospitals tend to skim off the more profitable cases, “siphoning resources away from full-service community hospitals.” ... NYTimes 07.06.08
The American Hospital Association, which represents 5,000 hospitals of all types, supports the proposal.
Doctor-owned hospitals “create a potential conflict of interest between a patient’s health care needs and the physician’s financial interests,” said Richard J. Pollack, executive vice president of the hospital association. Moreover, he said, doctor-owned specialty hospitals tend to skim off the more profitable cases, “siphoning resources away from full-service community hospitals.” ... NYTimes 07.06.08
Por outro lado:
The U.S. spends twice as much as other industrialized nations on health care, $7,129 per capita. Yet our system performs poorly in comparison and still leaves 47 million without health coverage and millions more inadequately covered.
Apesar de um grande número de HHs com estatuto de entidades com fins não lucrativos.
É este modelo de saúde que querem para o nosso país?
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Myth: For-profit ownership of facilities would lead to a more efficient healthcare system
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Overcrowded emergency rooms and waiting lists are frequently cited as evidence that healthcare is in trouble and proof that public healthcare doesn’t work. For patients, clinicians and others who experience these frustrations, it often seems that the way to a more efficient system is to allow for-profit companies to have a bigger role in running the healthcare system. Private sector efficiency and the profit motive are the cure for what ails the system, or so the argument goes.
But is this the solution? While enthusiasts argue that for-profit facilities can provide medical services more efficiently and with a lower price tag, the vast majority of studies shows the exact opposite. Research demonstrates that waiting lists and costs aren’t reduced with private forprofit contracts — and American literature indicates that patients who receive care in for-profit facilities are more likely to die than those in non-profit ones.
Public funding, private delivery
Most evidence examining for-profit healthcare comes from the United States, where there is a mix of private for-profit, private non-profit, and public hospitals. And that evidence is overwhelmingly in favour of not-for-profit healthcare.
For example, a recent review of 149studies and 20 years’ worth of data looked at how these facilities performed against each other in the areas of access, quality, and costeffectiveness.
The researchers looked at six types of institutions — hospitals, nursing homes, HMOs, hospices, dialysis centres, and psychiatric hospitals. They found that 88 of the studies concluded that non-profit centres performed better, while 43 studies found that the performance was no different. Only 18 studies found for-profit centres were better. The differences are particularly clear at psychiatric inpatient hospitals, where out of 17 studies, only one found for-profit facilities to be better.
American researchers have also examined what happens when governments pay for-profit hospitals to provide medical services. Using data from the federal Medicare program, researchers found health spending was higher and increased faster in communities served by for-profit hospitals compared to non-profit communities.
Between 1990 and 1994, for-profit hospitals billed roughly $8,115 for every discharged patient, while non-profit hospitals billed $7,490. For-profit hospitals also spent significantly more on administration for each patient day.
When it comes to patient health, the costs can be even higher. Research shows quality of care is better in the American non-profit system, which provides higher rates of immunization, mammography, and other preventive services.
A good example is dialysis and kidney transplants, which are funded through Medicare but provided by both for-profit and non-profit dialysis centres. Tragically, a recent systematic review that followed 500,000 dialysis patients for a year showed patients receiving treatment in for-profit centres are significantly more likely to die than those treated in nonprofit ones: expanded to all Americans who receive dialysis, this means as many as 2,500 premature deaths every year may be due to being treated at for-profit centres. As well, people treated at for-profit clinics are less likely to be referred for kidney transplants.
Despite this growing body of evidence, some researchers in Canada continue to question how relevant these American data are for Canadian policy, given the differences between the two systems in terms of purchasing, financing and delivery. However, since the evidence favouring non-profit care spans almost two decades, during which the American for-profit sector has gone through many changes in how it delivers care, it appears that forprofit care leads to higher mortality no matter what the administrative system is like.
Mixing it up
Advocates of for-profit healthcare often accuse Canada of having a “single-payer” system that is hostile to forprofit interests. However, there are already for-profit facilities in Canada, such as MRI clinics and other diagnostic centres, private laboratories, and other services. These have been defended on the grounds
that they will reduce waiting times.
Some provinces allow staff, doctors in particular, to work in both these public and private systems. Manitoba and Alberta, for example, have mixed delivery of cataract surgery, in both private and public facilities. And in both provinces, patients paid extra out-of-pocket fees for high-end lenses and facility fees until governments introduced legislation to stop the extra billing; the provincial health plans now pay for all related costs.
The problem with mixed delivery is that it may bleed resources away from the public system and into the private one. Doctors and nurses can’t be in two places at once, so it is possible the more care they provide in the for-profit sector, the less they can do in the public sector. This can lead to longer waiting lists for patients using the public system. While public/private cataract surgeons in Alberta and Manitoba did not neglect their public-sector patients for their private-sector ones, waiting times for cataract surgery are longer for public/private surgeons than for those who only work
in the public system. For-profit clinics exist to provide care, but the individuals who own and operate these ventures also need to make money. These goals can collide — and sometimes to the detriment of patients. As Robert Evans, a health economist at the University of British Columbia, says, “Profit motives are the same everywhere.”
March 2004
O sistema de Saúde Norte Amreicano é constituido por unidades privadas de fins lucrativos, não lucrativos e do Estado.
O Canadá tem um sistema do tipo Serviço Nacional de Saúde.
As diferenças entre os dois sistemas são marcantes quanto ao ACESSO, CUSTOS e RESULTADOS.
In 1999, health administration costs totaled at least $294.3 billion in the United States, or $1,059 per capita, as compared with $307 per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada’s national health insurance program had overhead of 1.3 percent; the overhead among Canada’s private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers’ administrative costs were far lower in Canada. link
Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations’ figures exclude insurance- industry personnel.)
conclusions
The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.
nejm, august 21, 2003
Este sim, a dar crédito ao relatos que referem um circulo vicioso de referenciação entre os "Physician-owned hospitals" , acrescido da utilização de procedimentos desnecessários, é um caso de promiscuidade na Saúde.
A posição expressa por Michael C. Burgess, a Texas Republican and an obstetrician-gynecologist, said Congress should “keep its hands off” doctor-owned hospitals.
“This is a free country,” Mr. Burgess said. “If you want to invest in a hospital, if you are willing to put personal capital at risk, you should not be forbidden to do so just because you are a doctor.” é um exemplo acabado do ultra-liberalismo a condicionar um País.
Por poutro lado, a posição da The White House opposes the limits on doctor-owned hospitals, saying they “could restrict patient choice without decreasing Medicare costs” — sustentada pela American Medical Association é gato escondido com o rabo de fora...
Não há Medicina credível sem, concomitantemente, estarem a ser aplicados no terreno, rigorosos e implacáveis, princípios éticos.
Mas o liberalismo que se pretende aplicar no nosso País é, substancialmente, diferente deste.
A "inciativa empresarial médica" em instuições de Saúde é, relativamente, reduzida e concentra-se, essencialmente, em MCDT (que estão a ser progressivamente alienados a grupos etrangeiros).
A posse dos Hospitais privados tende a ser um feudo do grande capital financeiro. Os que ainda resistem - poucos - estão a ser cercados e lá irão parar. Trata-se de um "mercado" de muitos milhões de euros que não podem ficar à discrição de "amadores".
Coverage
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The cost slowdown of the mid-1990s had a positive effect on access to private health coverage. The combination of rapid economic growth and significant cost control made health benefits more affordable for employers and therefore restrained the growth in the share of costs that employees would have to pay to cover their families. As a result, employment-based coverage reversed its decline and, between 1994 and 2000, rose from covering 64.4 percent of the population to covering 66.8 percent. Meanwhile, coverage for the needy through the Medicaid program declined from 12.7 percent of the population in 1994 to 10.5 percent in 1999, because of both the good economy (which reduced need) and the “welfare reform” that reduced participation in Medicaid. These trends, however, then reversed. By 2003 only 63 percent of Americans had health benefits through employment—a smaller percentage than in 1994. Meanwhile, governments in the late 1990s responded to favorable budget conditions by expanding Medicaid eligibility. When the economy then turned sour, Medicaid enrollments grew to 12.8 percent of the population by 2003—higher than in 1994 (Fronstin 2004, p. 5).
By March 2003, nearly 45 million Americans—about 17.7 percent of the population below the age of sixty-five (and thus ineligible for Medicare) had no health insurance. Holahan and Wang summarized the pattern: “The extent to which the loss of employer coverage resulted in people becoming uninsured depended on their access to public programs” (2004, p. W4–31).
Cost matters to access: when both governments and employers were doing well financially, they tended to maintain or expand coverage, and when they were not doing well, they reduced or, at best, maintained the same coverage. But the overall pattern suggests that government was a bit more likely to intentionally expand coverage in good times and to resist contracting coverage in bad times. The decrease in Medicaid enrollment in the mid-1990s did result in part from welfare reform. This reform was not driven by budget concerns, however, but by conservative ideology and general public disgust with the previous system. In addition, as written, the 1996 law was supposed to maintain the entitlement to Medicaid benefits. Much of the decline was viewed as a failure of state administration, and in the late 1990s, the states actually made efforts to rectify those failures of outreach. Medicaid turned out to have enough “support among coalitions of public officials, health care providers, and local advocates” to “protect the program in hard times and enlarge it when the clouds lift” (Hoadley, Cunningham, and McHugh 2004, pp. 143–44). It should be no surprise that private market dynamics are not as reliable a way to subsidize poor people as government is, even in the United States. Indeed, equity is not what markets are supposed to provide (Pauly 1998a).
Cost controls are good for payers and bad for providers. For example, the period of strong cost controls had particularly negative effects on major teaching hospitals. Not only were they (for a while) at some disadvantage in contracting with private insurers, but they were hit by the antifraud campaign in Medicare, and many of them made unsuccessful investments (such as purchasing physician practices) during the 1990s. MedPAC estimates that in 1999 at the peak of the effects of the Medicare restraint, the average operating margin for teaching hospitals had fallen to 0.2 percent, which means that many of them were in the red (MedPAC 2001, pp. 69–71).
Public policies did, however, ameliorate the effects on access. Safety-net hospitals benefited from the Medicare and especially Medicaid “Disproportionate Share Hospital” (DSH) programs (Zuckerman et al. 2001). Academic medical centers also received payments for medical education and benefited from the boom in National Institutes of Health funding at the turn of the century. Reduced income from the spread of “managed care” was associated with physicians providing less charity care (HSChange 1999). Shrinking inpatient capacity (in almost all markets) and facility closures (in many) did cause many problems with access to emergency departments; ambulances shunted from one emergency department to another became common by 2001. Yet these pressures were somewhat ameliorated by a mix of measures, including the expansion of community health centers, the reorganization of dispatching systems for ambulance services, and hospital managers’ choosing to expand emergency departments in hopes of catching more inpatients (Brewster and Felland 2004; Felland, Felt-Lisk, and McHugh 2004; Kellerman 2004; Melnick et al. 2004).
The basic pattern, then, was that the market did threaten the “safety net” but that the safety net was protected—mostly—by political decisions. By 2003 a larger proportion of Americans was uninsured than in 1993, and more Americans were dependent on government “safety-net” programs such as Medicaid and subsidies to community health centers and academic medical centers.
Joseph White, Markets and Medical Care: The United States, 1993–2005
Salvador de Mello defendeu sistema de livre concorrência
A qualidade do Sistema de Saúde Público vs Privado foi um dos temas em debate no XXVIII Congresso Nacional de Gastrenterologia e Endoscopia Digestiva com Salvador de Mello a defender a livre concorrência entre os sectores público e privado.
“A separação entre público e privado deverá desaparecer”, afirma o presidente do Grupo José Mello Saúde. Salvador de Mello defende um modelo em que "haja competitividade no sector, para a qual é preciso haver concorrência”. Estas afirmações foram proferidas durante o quadro “O Sistema de Saúde e a Qualidade em Gastrenterologia” em que o presidente do Grupo José Mello Saúde defendeu as “Vantagens do Sistema Privado.
A intervenção foi alvo de um acalorado debate em que alguns apontaram o dedo à “mercantilização” da saúde em Portugal. Alguns dos presentes defenderam o sistema público, acusando as entidades privadas de procurarem a quantidade apenas no que toca ao atendimento em detrimento da qualidade dos cuidados médicos. Salvador de Mello está convicto de que só num sistema de livre concorrência, a qualidade dos cuidados de saúde pode ser totalmente assegurada: “Devem ser os doentes a escolher onde querem ser tratados e o Estado deve garantir esse livre acesso. A concorrência é factor determinante para a melhoria de todos os sectores económicos, a saúde não é excepção”, defendeu.
Tudo indica que é este o modelo preconizado pela JMS. Até porque parece evidente que o seu principal responsável ainda não percebeu a diferença entre o mercado e o sistema de saúde. É certo que se houver mudança de ciclo político em 2009 uma nova versão de LFP nos levará ao desmantelamento do SNS. O pior, no entanto, não são os apetites económicos e financeiros mas antes a confrangedora percepção de que estes actores acreditam, mesmo, que o sector da saúde não é diferente dos combustíveis, da banca, dos seguros, etc. Cá estaremos para ver uma qualquer autoridade da concorrência a prestar-se a papéis tão tristes quanto aquele que vimos, recentemente, nos consumíveis. Só que neste caso estarão em causa direitos fundamentais. Enfim “it’s the market, stupid”
É interessante focar que a luta para a criação de um sistema universal nos EUA tem quase um século. Inúmeros Estados criaram sistemas que asseguram uma cobertura de saúde quase universal dos seus cidadãos: Califórnia, MaryLand, Colorado, Massachussets, Arizona.
O grande problema é que a grande número de seguros, não cobre todas as despesas de saúde(baixos níveis de comparticipaçã).
Temos que encarar o EUA com um vasto território com uma cultura muito diferente da europeia. Não passa na cabeça da maioria dos cidadãos dos EUA fazer descontos para um sistema , destinado a custear a despesas de saúde dos seus concidadãos.
Vale a pena ler os seguites textos:
It’s The Prices, Stupid:Why The United States Is So Different From Other Countries
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How Does The Quality Of Care Compare In Five Countries?
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