RESUMEN

Because of the epidemiological transition, the global burden of illness has changed. Several factors have contributed to this change, including improvements in maternal and child health, increasing age of populations, and newly recognized disorders of the nervous system. It is now evident that neurologic disorders have emerged as priority health problems worldwide. This is reflected in the Global Burden of Disease Study, jointly published by the World Health Organization and other groups. The proportionate share of the total global burden of disease resulting from neuropsychiatric disorders is projected to rise to 14.7% by 2020. Although neurologic and psychiatric disorders comprise only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with a disability. This study provides compelling evidence that one cannot assess the neurologic health status of a population by examining mortality statistics alone. Health ministries worldwide must prioritize neurologic disorders, and neurologists must be prepared to provide care for increased numbers of people individually and in population groups.

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Alzheimer's disease (AD) is a global priority public health problem, such that health ministries worldwide and medical education sectors alike need to prioritize resources for dementia research, education, and treatment. Many American opinion leaders in neurology hold to the maxim that the rising incidence and prevalence of AD in an aging population will create an increasing demand for the services of neurologists. With managed care on the march, however, a declining workload for practicing neurologists is far more likely, because until 2010 the number of neurologists will continue to expand more rapidly than the increasing burden of illness. Reform of medical education in support of the World Health Organization "Health for All" initiative can provide all physicians with a population-based perspective and a sense of social mission that encourages appropriate utilization of specialized resources and personnel. In the era of managed care, neurologic education should be broadened into the domain of mental illness to increase practice opportunities for graduating residents as behavioral neuroscientists. The capacity of AD referral centers to thrive in a cost-conscious managed care environment is crucially dependent on the ability and willingness of office-based neurologists with managed care contracts to make appropriate patient referrals to such centers. Neurologists who question the capacity of primary care physicians to provide the full range of specialized services should likewise question the quality of tertiary care carried out in a community framework of service provision.

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Since the collapse of federal health system reform legislation in 1994, there has been a growing concern with the quality of care provided within managed care systems. Just as physicians practicing under a traditional fee-for-service payment base have financial incentives to do as much as possible for each patient (doing well by doing good), physicians working for managed care plans are sometimes given perverse incentives to do as little as possible. A major quality-related concern among patients and payers (often referred to jointly and ambiguously as consumers of care) is the much larger role assigned to primary care physicians in managed care plans than is usually the case with traditional indemnity insurance.

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This study sought to reveal the patterns of medical care given to patients with neurologic diseases in Colombia. To that end, it tracked the daily activities of 30 neurologists chosen from a representative sample of 119 neurologists registered in Colombia in 1993. The information was requested by means of a previously standardized questionnaire and was complemented by demographic and epidemiologic data. The results showed that demand for specialized neurologic care depended more on cultural perceptions than on objective measures of prevalence. Moreover, it was found that education in neurology should place greater emphasis on ambulatory treatment as an alternative to hospital treatment. The survey also offered preliminary information on the prevalence and incidence of the primary neurologic diseases in the country. The prevalence of these diseases far exceeds the supply of specialized neurologic care. Finally, the results point out the advantages and deficiencies of this type of care, findings that might guide future efforts in this field in other countries and under different circumstances.

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The demise of the federal health system reform legislation in 1994 means that the unplanned, market-driven revolution already in motion will proceed unchecked by such social concerns as a requirement to provide health insurance for the 40 million people without health insurance. Managed care has expanded as a market response to spiraling health care costs and has already changed the matrix of health services provision dramatically in some regions. The rapid growth of large for-profit corporations sponsoring managed care plans has displaced nonprofit health maintenance organizations (HMOs) as the dominant force in prepaid group practice. As of 1993, fewer than half of all people with health insurance were covered by traditional indemnity insurance and most observers now expect that not more than 10% of the population will still be covered by unmanaged fee-for-service health insurance in the year 2000, while two thirds of the population will be enrolled in managed care plans with strong physician utilization guidelines.

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