RESUMO
BACKGROUND: Lupus is a chronic autoimmune and incurable rheumatic disease and has a global prevalence of 3.2-517.5 cases per 100,000 people. However, currently there is no knowledge regarding the actual direct cost of patients with lupus to healthcare systems in developing countries. This study aimed to determine the direct cost of lupus care in Colombia. METHODS: To identify patients with lupus, claims data of 2 years from two health insurers were subjected to an algorithm according to International Statistical Classification of Diseases and Related Health Problems 10th Revision codes. Multivariate linear regression analyses were used to assess the direct cost of lupus care. RESULTS: The average annual per-patient, all-claims, all-cause direct cost was $2355; this is approximately 9 times the average annual premium received by health insurers for covering the public benefits package. Approximately 50% of direct costs are not included in the public benefits package. The incidence of one or more condition is 98.4%. The direct cost incurred by patients with two comorbidities was 1.8 times more, with three chronic conditions was 1.9 times more and with six chronic conditions was 4.5 times more than that incurred by patients with only lupus. CONCLUSIONS: The direct cost of lupus care in the developing world may be higher than expected; in addition, access to healthcare may not be equal for the entire population.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Lúpus Eritematoso Sistêmico/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Doença Crônica , Colômbia , Comorbidade , Efeitos Psicossociais da Doença , Países em Desenvolvimento , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Revisão da Utilização de Seguros/estatística & dados numéricos , Modelos Lineares , Lúpus Eritematoso Sistêmico/terapia , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: To compare patient experiences and disparities for older adults with depressive symptoms in managed care (Medicare Advantage [MA]) versus Medicare Fee-for-Service (FFS). DATA SOURCES: Data came from the 2010 Medicare CAHPS survey, to which 220,040 MA and 135,874 FFS enrollees aged 65 and older responded. STUDY DESIGN: Multivariate linear regression was used to test whether case-mix-adjusted associations between depressive symptoms and patient experience differed for beneficiaries in MA versus FFS. Dependent measures included four measures of beneficiaries' experiences with doctors (e.g., reports of doctor communication) and seven measures of beneficiaries' experiences with plans (e.g., customer service). PRINCIPAL FINDINGS: Beneficiaries with depressive symptoms reported worse experiences than those without depressive symptoms regardless of coverage type. For measures assessing interactions with the plan (but not for measures assessing interactions with doctors), the disadvantage for beneficiaries with versus without depressive symptoms was larger in MA than in FFS. CONCLUSIONS: Disparities in care experienced by older Medicare beneficiaries with depressive symptoms tend to be more negative in managed care than in FFS. Efforts are needed to identify and address the barriers these beneficiaries encounter to help them better traverse the managed care environment.
Assuntos
Depressão/psicologia , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Programas de Assistência Gerenciada/estatística & dados numéricos , Medicare/estatística & dados numéricos , Satisfação do Paciente , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comunicação , Depressão/epidemiologia , Escolaridade , Feminino , Nível de Saúde , Disparidades em Assistência à Saúde , Humanos , Modelos Lineares , Masculino , Relações Médico-Paciente , Fatores Sexuais , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Managed competition has underpinned most health sector reforms aimed at improving access and efficiency, in Latin America and other countries. The aim of the paper is to analyse barriers to healthcare that emerge from the introduction of managed care mechanisms in Colombia. METHODS: Qualitative, exploratory, and descriptive-interpretative research was carried out on the basis of case studies of four healthcare networks, comprised of insurers and their providers. Individual semi-structured interviews were conducted with a theoretical sample of informants (managers, professionals, and users), between 24 and 61 per network. The final sample size was reached by saturation of information. An inductive thematic content analysis was conducted. The study areas were two municipalities of Colombia, in which most of the population live in poverty. RESULTS: A number of managed care mechanisms that act as barriers to access were identified by all informants, regardless of area and type of insurance regime. These mechanisms act directly on the patient (authorizations, fragmented insurance) or on the providers (purchasing mechanisms or limits to medical practice). The predominant mechanism appears to be related to the type of agreement established between insurers and providers. The reason for these barriers, according to informants, is insurers' search for profitability. As a consequence, there is delay in or no access to adequate treatment. This is particularly evident in secondary care. CONCLUSION: A variety of managed care strategies that effectively hinder access to healthcare have been introduced by insurers, casting doubt on the usefulness of their application in low-income countries and profit-making contexts.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Programas de Assistência Gerenciada/estatística & dados numéricos , Colômbia/epidemiologia , Atenção à Saúde/organização & administração , Atenção à Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Seguro Saúde/organização & administração , Seguro Saúde/estatística & dados numéricos , Programas de Assistência Gerenciada/organização & administração , Modelos Organizacionais , Estudos de Casos Organizacionais , Pesquisa QualitativaRESUMO
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
Assuntos
Serviços de Saúde Comunitária/organização & administração , Agentes Comunitários de Saúde , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Redução de Custos , Pesquisa sobre Serviços de Saúde , Humanos , New Mexico , Avaliação de Resultados em Cuidados de Saúde , Defesa do Paciente , Educação de Pacientes como Assunto , Estudos Retrospectivos , Apoio Social , Estados UnidosRESUMO
In 2005, New Mexico began a comprehensive reform of state-funded mental health care. This paper reports on differences in characteristics, infrastructure, financial status, and services across mental health agencies. We administered a telephone survey to senior leadership to assess agency status prior to and during the first year of reform. Non-profit/public agencies were more likely than others to report reductions or no changes in administrative staff. CMHCs were more likely to report a decline in their financial situation. Findings demonstrated that CMHCs, non-profit/public agencies and rural agencies were more likely to offer critical services to adults with serious mental illness.
Assuntos
Reforma dos Serviços de Saúde/organização & administração , Programas de Assistência Gerenciada/organização & administração , Serviços de Saúde Mental/organização & administração , Setor Público , Adolescente , Adulto , Pesquisas sobre Atenção à Saúde , Humanos , Programas de Assistência Gerenciada/estatística & dados numéricos , Transtornos Mentais/terapia , Saúde Mental , Serviços de Saúde Mental/legislação & jurisprudência , Pessoa de Meia-Idade , New Mexico , Administração em Saúde Pública/economia , Política Pública , População Rural , Índice de Gravidade de Doença , Inquéritos e Questionários , Telefone , População Urbana , Adulto JovemRESUMO
OBJECTIVE: The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care. DATA SOURCES/STUDY SETTING: The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico. STUDY DESIGN: Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression. DATA COLLECTION/EXTRACTION METHODS: Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population. PRINCIPAL FINDINGS: System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness. CONCLUSION: Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.
Assuntos
Depressão/economia , Depressão/terapia , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/estatística & dados numéricos , Adolescente , Adulto , Idoso , Análise Custo-Benefício , Depressão/diagnóstico , Feminino , Humanos , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Pobreza , Guias de Prática Clínica como Assunto , Escalas de Graduação Psiquiátrica , Porto Rico , Resultado do TratamentoRESUMO
The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.
Assuntos
Programas de Assistência Gerenciada/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Avaliação das Necessidades , Revisão da Utilização de Recursos de Saúde/métodos , Adolescente , Alocação de Recursos para a Atenção à Saúde/métodos , Humanos , Masculino , New Mexico , Estudos de Casos Organizacionais , Recusa em TratarRESUMO
BACKGROUND: We wanted to examine the association between Medicaid managed care (MMC) and changing immunization coverage in New Mexico, a predominantly rural, poor, and multiethnic state. METHODS: As part of a multimethod assessment of MMC, we studied trends in quantitative data from the National Immunization Survey (NIS) using temporal plots, Fisher's exact test, and the Cochran-Armitage trend test. To help explain changes in immunization rates in relation to MMC, we analyzed qualitative data gathered through ethnographic observations at safety net institutions: income support (welfare) offices, community health centers, hospital emergency departments, private physicians' offices, mental health institutions, managed care organizations, and agencies of state government. RESULTS: Immunization coverage decreased significantly after implementation of MMC, from 80% in 1996 to 73% in 2001 for the 4:3:1 vaccination series (Fisher's exact test, P = .031). New Mexico dropped in rank among states from 30th for this vaccination series in 1996 to 50th in 2001. A significant decreasing trend (Cochran-Armitage P = .025) in coverage occurred between 1996 and 2001. Findings from the ethnographic study revealed conditions that might have contributed to decreased immunization coverage: (1) reduced funding for immunizations at public health clinics, and difficulties in gaining access to MMC providers; (2) informal referrals from managed care organizations and contracting physicians to community health centers and state-run public health clinics; and (3) increased workloads and delays at community health centers, linked partly to these informal referrals for immunizations. CONCLUSIONS: Medicaid reform in New Mexico did not improve immunization coverage, which declined significantly to among the lowest in the nation. Reduced funding for public health clinics and informal referrals may have contributed to this decline. These observations show how unanticipated and adverse consequences can result from policy interventions in complex insurance systems.
Assuntos
Reforma dos Serviços de Saúde , Programas de Imunização/organização & administração , Imunização/estatística & dados numéricos , Programas de Assistência Gerenciada/organização & administração , Medicare/organização & administração , Planos Governamentais de Saúde/organização & administração , Antropologia Cultural , Criança , Pré-Escolar , Acessibilidade aos Serviços de Saúde , Humanos , Programas de Imunização/economia , Programas de Imunização/estatística & dados numéricos , Lactente , Programas de Assistência Gerenciada/estatística & dados numéricos , Medicare/estatística & dados numéricos , New Mexico , Avaliação de Processos e Resultados em Cuidados de Saúde , Planos Governamentais de Saúde/estatística & dados numéricos , Estados UnidosRESUMO
OBJECTIVE: To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines. DESIGN: Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity. RESULTS: Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing. CONCLUSIONS: There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist.
Assuntos
Asma/terapia , Fidelidade a Diretrizes/normas , Programas de Assistência Gerenciada/normas , Pediatria/normas , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde , Adolescente , Asma/diagnóstico , Asma/etiologia , Atitude Frente a Saúde , Criança , Pré-Escolar , Estudos Transversais , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Meio-Oeste dos Estados Unidos , Avaliação das Necessidades/organização & administração , New England , Avaliação de Resultados em Cuidados de Saúde , Pais/educação , Pais/psicologia , Educação de Pacientes como Assunto/normas , Pediatria/métodos , Pediatria/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Índice de Gravidade de Doença , Inquéritos e Questionários , Gestão da Qualidade Total/organização & administraçãoRESUMO
This paper estimates the impact of managed care on use of mental health services by residents of low-income areas in Puerto Rico. A quasi-experimental design evaluates the impact of a low capitation rate on a minority population using three waves of data from a random community sample. Results indicate that two years after introducing managed care, privatization of mental health services had minimal impact on use. Advocates had hoped health care reform would increase access in comparison to access seen within the public system, while opponents feared profit motives would lead to decreased access. Neither forecast turned out to be correct. The question remains as to how to improve access for the poor with low capitation rates.
Assuntos
Capitação , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Serviços Contratados/organização & administração , Reforma dos Serviços de Saúde , Programas de Assistência Gerenciada/estatística & dados numéricos , Medicaid/organização & administração , Adolescente , Adulto , Idoso , Serviços Comunitários de Saúde Mental/organização & administração , Feminino , Acessibilidade aos Serviços de Saúde/organização & administração , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Programas de Assistência Gerenciada/organização & administração , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Áreas de Pobreza , Privatização , Porto Rico , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
Se realizó una evaluación descriptiva y transversal sobre la calidad de la aplicación del programa Nacional de Diagnóstico Precoz del Cáncer Bucal(PDCB), en el municipio de Santiago de Cuba, durante el semestre enero-junio de 1998, para lo cual se empleó la metodología propuesta por R.H.Palmer. Se consultó a un grupo de expertos en el tema de investigación y se obtuvieron los criterios, indicadores y estándares que fueron utilizados para evaluar la estructura, el proceso y los resultados del programa.La evaluación reveló dificultades organizativas de este último enel terrritorio, serios problemas estructurales que conspiran contra la calidad de la asistencia, deficiente cobertura de pacientes examinados e insuficiente cantidad y calidad de actividades educativas para los profesionales y población incluida en el programa.Se recomendó extender esta línea de investigación a todas las unidades estomatológicas de la provincia y llevar acabo una estrategia de intervención para resolver los inconvenientes hallados
Assuntos
Humanos , Masculino , Feminino , Adulto , Avaliação de Programas e Projetos de Saúde/tendências , Neoplasias Bucais/epidemiologia , Programas de Assistência Gerenciada/estatística & dados numéricosAssuntos
Hospitais de Ensino , Programas de Assistência Gerenciada , Faculdades de Medicina , Orçamentos , Controle de Custos , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Acessibilidade aos Serviços de Saúde , Hospitais de Ensino/economia , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/estatística & dados numéricos , Maryland , National Institutes of Health (U.S.) , Médicos/economia , Atenção Primária à Saúde/economia , Apoio à Pesquisa como Assunto , Faculdades de Medicina/economia , Estados UnidosRESUMO
In 1997, PHS enhanced its presence in the managed care market by adding a large HMO to its health plan and snagging the largest part of state Medicaid managed care contracts. The health plan, once the source of only 15% of the system's revenue, is fast becoming the dominate component of the healthcare delivery system--a source of discontent for those who liked the old system. Find out the strategy behind these changes and plans for the future.
Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Programas de Assistência Gerenciada/organização & administração , Área Programática de Saúde , Planejamento em Saúde Comunitária , Conselho Diretor/organização & administração , Nível de Saúde , Humanos , Programas de Assistência Gerenciada/estatística & dados numéricos , Programas de Assistência Gerenciada/tendências , New Mexico , Estudos de Casos Organizacionais , Objetivos Organizacionais , Admissão do Paciente/estatística & dados numéricos , Sudoeste dos Estados UnidosRESUMO
El crecimiento cada vez mayor de los costos que demanda la atención de la salud, coloca a la sociedad y a los gobiernos en situaciones conflictivas y espinosas y creemos que es útil pretender soluciones de tipo coyuntural. Con frecuencia nos olvidamos que dentro la Seguridad Social, la atención de la salud representa un compromiso social, cuyo verdadero alcance no se puede captar, si el análisis no se sitúa en una prespectiva de largo alcance y que incluya inexorablemente la cobertura recional y completa del nivel primario de salud
Assuntos
Masculino , Feminino , Humanos , Estratégias de Saúde , Implementação de Plano de Saúde , Programas de Assistência Gerenciada , Programas de Assistência Gerenciada/estatística & dados numéricos , Programas de Assistência Gerenciada/normas , Programas de Assistência Gerenciada/organização & administração , Análise de Situação , Visão OcularRESUMO
Existen evidencias concretas de que la maternidad en adolescentes implica un riesgo biopsicosocial para la madre, niño, familia y comunidad. La aplicación de una intervención P.A.I.A.E. (Programa de Atención Integral de la Adolescente Embarazada) durante el embarazo en adolescentes determinó mejores resultados obstétricos y perinatales. En este estudio se planteó la hipótesis: la atención integral de la adolescente durante la gestación, con énfasis en el fortalecimiento del vínculo madre-hijo, atenúa los efectos de un ambiente familiar social y económico depravado en el desarrollo psicomotor del niño preescolar. En el diseño de la investigación se tuvo presente que el desarrollo psicomotor del niño no puede circunscribirse a una variable causal, edad de la madre, sino que obedece a un modelo multicausal, lo que determinó el estudio del nivel socioeconómico y redes de apoyo social como forma de aproximación al contexto en que vive el niño. La población en estudio estuvo constituida por niños preescolares cuyas madres, durante la gestación, fueron atendidas por el P.A.I.A.E. Como grupo testigo se reclutó a preescolares, también hijos de adolescentes, quienes controlaron su embarazo a través del programa materno perinatal oficial. Los resultados de la valoración del desarrollo psicomotor muestran que las diferencias entre los grupos en la prueba total y en las tres áreas que lo componen no son estadísticamente significativas, por tanto se rechaza la hipótesis. La estratificación del nivel socioeconómico y el análisis de cada variable contenida en la escala de medición demuestran que hay un contexto socioeconómico depravado. Además, una muy baja proporción de los niños recibe asistencia pedagógica, lo que resalta el papel que cumplen la madre y familia en el desarrollo del niño. El estudio de correlación entre las variables biosociales del niño y el nivel socioeconómico, en cada grupo, muestra que cuando ésta fue significativa, p < 0,05, su intensidad era generalmente débil
Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Desenvolvimento Infantil , Gravidez na Adolescência/estatística & dados numéricos , Desempenho Psicomotor , Relações Mãe-Filho , Programas de Assistência Gerenciada/estatística & dados numéricos , Transtornos Psicomotores/epidemiologia , Transtornos Psicomotores/prevenção & controle , Apoio Social , Fatores SocioeconômicosRESUMO
Based on an inquiry that yielded national socioeconomic information, health inequalities among different quintiles of per capita income were explored in southeast and west helath services of the metropolitan region. Inequalities were assessed establishing the type of health plan (state or private), ocurrence of disease, access to medical attention and medications and use of health services. Fifty-eight percent of individuals living in the southeast health service and 74 percent of those living in the west health service had a state funded health plans. This proportion was higher among subjects with lower earnings. One third of the population studied had a disease in the last three months. Ninety percent of these had medical attention. Most subjects that did not receive professional care, medicated them and felt that they did not require it. Subjects with lower earnings had greater difficults to obtain medical attention or medications. Primary care comprises 62 percent of health actions and state funded sector is used by 88 percent of subjects of the first quintile of per capita income