A Politica da Saúde – primeiro debate da tertúlia “1 ano depois da troika”

Posted by Pedro Pita Barros in Sem categoria

Decorreu quinta-feira passada a primeira de três sessões:

 

A Política da Saúde

Moderador: Adalberto Campos Fernandes, pergunta de abertura: temos razões para estar satisfeitos com o primeiro ano da troika?

As respostas: não há razão para grande alegria, dado o motivo da existência da troika.

Para estarmos mais satisfeitos, devia-se ver o tratamento e acompanhamento da doença crónica. São muitas medidas. A maior parte delas era

Não foi unânime a interpretação dos dados sobre alteração do recurso aos cuidados de saúde (aumento de consultas, redução de urgências).

Foi apontada a falta de um plano estratégico.

Foi defendido que para manter o SNS não é necessário que o Estado seja o prestador directo de todos os serviços.

É um problema o estado não cumprir com os compromissos assumidos em termos financeiros.

Adalberto: No segundo aniversário como imagina que será a festa?

Assumir discurso estratégico em que se assumam mudanças.

Valorizar o plano nacional de saúde, na actuação das ARS.

Houve intervenções, para além dos convidados e moderador, de João Varanda Fernandes, A Gentil Martins, eFranklin Ramos.

E já estão as cadeiras à espera do próximo debate.

Taxas moderadoras e isenções

Posted by julianperelman in Sem categoria, Taxas moderadoras

O BE propõe que sejam isentos de taxas moderadoras (TM) os doentes crónicos e portadores de doenças raras (que passo a referir como “doentes”), tal como era o caso antes da revisão. Percebe-se o argumento. Os doentes têm um consumo maior, e portanto correm um maior risco de ter de suportar uma despesa elevada. Se a despesa for demasiado elevada, os doentes podem ser obrigados a limitar um consumo necessário (não ir a consulta, comprar apenas uma parte dos medicamentos receitados, evitar  fazer exames…etc.). Ou, alternativamente, correm o risco de ter de se endividar ou de se tornarem pobres por causa da sua doença. Ou seja, percebe-se que nestas situações, o aumento das TM possa, apesar das isenções, criar iniquidade no acesso, e criar uma falha na função de “seguro” do SNS, que é a de evitar o empobrecimento por causa da saúde e  favorecer a redistribuição dos não doentes para os doentes. No entanto, o essencial desta questão é mais uma vez o rendimento e a despesa, e não tanto a doença. Primeiro, a despesa em saúde pode ser elevada por várias razões que não apenas a doença crónica ou rara. Segundo, um doente pode ter uma despesa elevada e no entanto ser rico, e poder pagar as TM, ou ser pobre, e ser isento das TM.  Portanto a “despesa elevada” é um conceito relativo que depende do rendimento da pessoa. Terceiro, mais vale definir isenções baseadas no valor da despesa e do rendimento das pessoas, conceitos verdadeiramente relevantes quando nos preocupamos com equidade e empobrecimento, e não no conceito de “doença crónica”, “doença rara”, nem sempre bem definidos e portanto também sujeito a interpretações ambiguas.

A melhor forma de lidar com esta questão no meu entender é  criar um “máximo de facturação” baseado no rendimento, como existe noutros países, ou seja, um limite de despesa após o qual o utente fica isento As isenções actuais são para pessoas que ganham por mês menos de 1,5 vezes o indexante de apoios sociais (IAS), ou seja 628€. Consideremos um critério utilizado na literatura, de que as despesas com a saúde que ultrapassam um limiar de 20% do rendimento são consideradas como “catastróficas” (ver por exemplo o artigo de Ke Chu e colegas na revista Lancet  do 12 de Julho de 2003). Ou seja, não seria aceitavel que a despesa chegue a este valor, e portanto deveria ser estabelecido por exemplo um critério de 15% após o qual o utente ficaria isento. Para dar um exemplo, uma pessoa que ganhe por mês 2 vezes o IAS (838€) seria isenta de TM quando a sua despesa ultrapassa 126€ (o que é de facto muito para quem ganha 838€). Ou seja, o valor de 126€ seria o seu “Máximo de Facturação” (MF). Para simplificar a regra e evitar uma sobrecarga administrativa, podia aplicar-se um critério deste tipo:

-       MF de 94€ para as pessoas que ganham entre 1,5 e 2 vezes o IAS (entre 628 e 838€), ou seja 15% do rendimento mais baixo do intervalo;

-       MF de 126€ para as pessoas que ganham entre 2 e 2,5 vezes o IAS (entre 838€ e 1.047€), ou seja 15% do rendimento mais baixo do intervalo;

-       MF de 189€ para as pessoas que ganham entre 2,5 e 3 vezes o IAS (entre 1.047 e 1.257€), ou seja 15% do rendimento mais baixo do intervalo.

Apenas estes critérios de rendimento e despesa são relevantes quando se trata de lidar com equidade e seguro, embora tanto a despesa como o rendimento estejam profundamente relacionados com a saúde das pessoas.

Julian Perelman

 

sobre o encerramento da Maternidade Alfredo da Costa

Posted by Pedro Pita Barros in Governo, Hospitais, Ministério da Saúde, Serviço Nacional de Saúde, Sistema de saúde português

escrevi aqui, com alguns números, e que repito neste blog

 

Agora sim, alguns números sobre a actividade de partos na zona de Lisboa
(embora a Maternidade Alfredo da Costa tenha alguma outra actividade para além dos partos, esta é a principal).
Os valors são baseados nos episódios classificados nos GDHs 370 – 375, 650 – 652
O primeiro passo foi perceber onde nascem as pessoas do concelho de Loures, para ter uma ideia dos principais hospitais afectados pela abertura do novo hospital de Loures, admitindo que haverá uma preferência por esse hospital (mais perto da zona de residência).
Assim, 70% dos partos correspondentes a pessoas que indicaram viver no concelho de Loures ocorreram na Maternidade Alfredo da Costa, 19% no Hospital de Santa Maria, 5,4% no Hospital de São José, 2,1% no Hospital S. Francisco Xavier e 2,4% em outros 9 hospitais diversos.
Olhando apenas para os 4 hospitais mais relevantes, o quadro tem a informação sobre o número absoluto de partos nesse hospital (qualquer que seja a origem geográfica), o número de partos no hospital que tem como origem  geográfica o hospital de Loures e a diferença, que será uma previsão (tosca) do número de partos caso todos os partos com origem no concelho de Loures se desloquem para o novo hospital. O número para o total de partos na Maternidade Alfredo da Costa não é exactamente o mesmo referido em notícias na imprensa, tendo como fonte uma médica da Maternidade, mas é suficientemente próximo para se estar dentro das magnitudes relevantes.
Total de partos vindos do concelho de Loures Total de partos no hospital Total de partos s/ Loures
Hospital de São José 168 2008 1840
Maternidade Dr. Alfredo da Costa 2172 5304 3132
Hospital de São Francisco Xavier 65 2861 2796
Hospita de Santa Maria 592 2622 2030
(nota: números referentes a 2010)
Sobre estes números,  o Hospital de Santa Maria parece sofrer pouco, já a MAC é quem perde mais, e podia absorver todos os partos que restam no Hospital de  Santa maria, ou os do Hospital S. José.
A questão é saber se é melhor deslocar os cerca  de 3132 partos que se podem prever para a Maternidade Alfredo da Costa nos outros hospitais, nomeadamente H. Santa Maria e H. São José ou fechar a maternidade numa destas unidades e passar todos os partos referentes a ela para a Maternidade Alfredo da Costa.
O principal contra desta solução é como ambos o H de S. José e o H. de Santa Maria têm ensino universitário de Medicina, não faz muito sentido encerrar as maternidades dessas unidades.
Assim, a alternativa mais lógica fica a ser fechar a maternidade do H. S. Francisco Xavier, direccionando a respectiva actividade de partos para o H. de S. José e para a Maternidade Alfredo da Costa, mas isso fará pouco sentido também dada a população servida pelo H. S. Francisco Xavier.
Estas observações beneficiariam de ter informação sobre as capacidades das diversas unidades hospitalares em causa, o que não consegui recolher (ainda, pelo menos), mas de qualquer modo creio que permitem uma visão mais clara – a abertura do novo hospital em Loures retira um número substancial de partos da Maternidade Alfredo da Costa. Esta fica então com capacidade por utilizar. O efeito sobre outros hospitais é menor, e o que mais é afectado depois da Maternidade Alfredo da Costa é o Hospital de Santa Maria.
A capacidade disponível na MAC é capaz de absorver toda a actividade de partos de um dos dois hospitais associados com Faculdades de Medicina (Hospital de Santa Maria – Faculdade de Medicina da Universidade de Lisboa, Hospital de S. José – Faculdade de Ciências Médicas). Mas precisamente por estes últimos hospitais serem universitários, fará mais sentido concentrar a actividade neles do que retirar de lá actividade, um argumento diferente da questão de unidades monovalentes (como a MAC) vs integradas em hospitais gerais. Assim, para manter a actividade da MAC sem haver capacidade instalada não utilizada, a solução teria que passar por deslocar actividade de outro hospital da zona de Lisboa. Só que os únicos com actividade suficiente seriam o Hospital de S. Francisco Xavier ou parte da actividade do Hospital de Amadora Sintra. Servindo esses hospitais sobretudo populações ao redor de Lisboa, a centralização dentro de Lisboa aparenta ser uma solução menos razoável do que deslocar as equipas da Maternidade Alfredo da Costa para outras unidades hospitalares.
(Nota final: estas informações e opinião poderão ser corrigidas se entretanto se obtiver informação mais actualizada ou mais completa. Agradeço aos leitores do blog que me enviaram sugestões, mesmo que a minha opinião não vá de encontro à sua).

vindo do outro lado do Atlântico,

Posted by Pedro Pita Barros in Noticias

uma visão baseada em conversas várias:

www.chicagotribune.com/topic/sns-rt-portugal-economyhealthcare-analysisl3e8et5fx-20120329,0,713814.story

chicagotribune.com

ANALYSIS-Portugal ponders political price of good health

Reuters

9:11 AM CDT, March 29, 2012

* Portugal struggles to please IMF, public on health cuts

* On health costs, Lisbon holds up mirror to other economies

* Future of basically free, universal access model at stake

* Euro crisis is dry run for future health budget battles

By Alan Wheatley and Daniel Alvarenga

LISBON, March 29 (Reuters) – To get an idea of the enormous
financial strains on Europe’s health care sector, put yourself
in the shoes of Professor Joao Alvaro Correia da Cunha.

As head of North Lisbon hospital centre, one of Portugal’s
largest, da Cunha has already slashed salaries by 20 percent and
shed 150 staff as part of cuts demanded by international lenders
in return for bailing out the government to the tune of 78
billion euros. He is under orders to keep cutting.

Yet da Cunha, a doctor for 43 years, is not ready to
compromise on his calling to heal the sick. In February he spent
1 million euros to treat a woman with a complex blood disease
and will soon prescribe a new drug for 25 people with a fatal
degenerative nerve disorder endemic in northern Portugal. The
cost will be perhaps 200,000 euros a year per patient.

Portugal’s taxpayer-funded national health service (NHS)
provides universal access, more or less free at the point of
delivery, and da Cunha is proud that his hospital has never had
to turn away a patient. He finds rationing of health care
anathema. Yet times are tough.

“If it comes to the point when it’s necessary to decide
whether we can treat a patient or not, then that decision will
not be mine. I’d rather retire,” he said. “And you shouldn’t
have to look in your pocket to see if you can afford to be
treated. But I agree we’re reaching the limit: we have no money.
The country is in crisis.”

Portugal is in particularly dire straits because it is in
hock to its lenders, with terms dictated by officials from the
“troika” of the International Monetary Fund, the European
Commission and the European Central Bank.

But the financial pressure that its medical system faces is
replicated across the continent. Spain, for instance, is bracing
for health cuts as part of an austerity budget promised by new
Prime Minister Mariano Rajoy.

The debate on the scope of health care spending may have
been triggered by the euro zone’s debt drama, but it will not go
away when the crisis ebbs.

“It will be unavoidable to rethink the resource allocation
mechanism. Of course, in health most countries don’t want to
talk about explicit rationing. The political cost is too high,”
said Professor Monica Oliveira, an expert in health finance at
the Technical University of Lisbon.

GOOD HEALTH, FINANCIAL PAIN

Standard & Poor’s, a credit ratings agency, recently warned
that health bills, compounded by the cost of caring for ageing
populations, were likely to become unaffordable for the Group of
20 major economies unless governments changed their social
protection systems.

Total health care spending has risen by more than 70 percent
in real terms in the OECD area since the early 1990s. Public
spending on health absorbs more than 6 percent of GDP and could
increase by another 3.5 to 6 percentage points by 2050,
estimates the Organisation for Economic Cooperation and
Development, a Paris-based forum of 34 mature economies.

People are living longer, while medical technology and
treatments are improving all the time. This is forcing
governments – and voters – to make unpalatable financing
choices. Is it possible to put a price on health? How much are
we prepared to pay to extend a life by a few weeks or months?

Seen in that light, today’s cost-cutting in Portugal is only
a dry run for a more fundamental reassessment of how the country
should pay for health care. Public and private spending on
health totalled 10.1 percent of GDP in 2009, well short of the
U.S. level of 17.4 percent but above the OECD average of 9.6
percent.

“We cannot undertake financing reforms when we are going
through a troika programme. But as soon as we’re through it,
we’ll have to start discussing financing. If not, the system
will be unsustainable. This is something that everybody has to
understand,” said Fernando Leal da Costa, a secretary of state
in the health ministry.

Like several experts interviewed for this report, da Costa
said he expected a mixed system to evolve in Portugal; the state
would continue to fund core services, but people would be asked
over time to pay more out of their own pocket.

“If we don’t try to do things smoothly now, we’ll probably
not avoid a catastrophe,” da Costa said.

With the troika’s bean counters bearing down, things are
currently far from smooth. The government is desperate for more
people to seek treatment in primary care centres instead of in
hospitals, which are more expensive. It also needs to close some
old hospitals to increase efficiency but has been shy of
offending local interests by shutting wards that are surplus to
capacity.

“The government is in the emergency room. They’re trying to
keep the patient alive,” said Isabel Vaz, chief executive of
Espirito Santo Health, a private hospital group. “They’re making
a huge effort to control costs, but I don’t know how they’re
going to put in place all the reforms they need without money.”

DOUBLE COVERAGE

In the longer term, Vaz said Portugal needed to reduce
duplication: around two million people or about 20 percent of
the population have access to private medical care – which is
subsidised for civil servants – as well as the NHS. This “double
coverage” is not efficient economically because it means paying
twice to cover the same risk, she argued.

Vaz advocated the sort of model used in Germany and the
Netherlands. “We’d have a social package so that everyone has
access to basic care and people would have to top up,” Vaz said.
“But that of course means a different way of looking at the
private-provision sector.”

Talk of tampering with the NHS is heresy to many Portuguese,
who cherish the system as a symbol of the country’s transition
to democracy after the overthrow of its dictatorship in 1974. It
is no accident that Britain’s health service, set up after World
War Two and generally held in similarly high esteem, served as a
model for that in Portugal.

The attachment to the NHS, founded in 1979, is not just
sentimental. People see the results of big investments in
health. In 1970, Portugal, western Europe’s poorest country,
recorded a shocking 55.5 infant deaths per 1,000, twice as many
as in neighbouring Spain. By 2009, the rate was down to 3.6.

Over the same period, life expectancy at birth improved from
67.1 to 79.5, the OECD average.

No one is more devoted to the NHS than Antonio Arnaut, a
lawyer who set up the system when he was minister of social
services.

“Today, everyone is equal when it comes to disease. Health
is a right, not a privilege of those who can pay, as it used to
be and is still the case in the United States, for example,” he
said in an interview in his office in Coimbra, a university town
north of Lisbon.

A founding member of Portugal’s Socialist Party, which is
now in opposition, Arnaut is not against private health
insurance and acknowledges there is a lot of scope to reduce
waste. But he says the debate is less about financing and more
about the political will to preserve what has become, in his
eyes, a fundamental right.

“If the government cuts so much that the NHS loses its
character, there’ll be a popular revolt, because only revolt can
recompense for the humiliation of the oppressed,” Arnaut, who is
also a poet and essayist, said.

SPREADING THE PAIN

Most Portuguese seem inured to the need for belt-tightening
to cut the government’s budget deficit to the EU threshold of 3
percent of GDP next year, but there is no doubt that the pain of
the health cuts is being felt widely.

Da Cunha, the Lisbon hospital head, is planning to reduce
his bill for drugs and medical consumables by another 10 percent
this year, but the mean salary of his 6,700 professional staff,
including three chaplains, has already fallen 20 percent over
two years to 1,200 euros a month.

“We can’t reduce our salaries any further,” he said simply.

Portuguese have had to pay more for consultations and
prescriptions since the start of the year, and patients in rural
Portugal no longer automatically enjoy free transport if they
have to go to the city for treatment.

Apolinario Eduardo, 36, who has just landed a job as a taxi
driver in Coimbra, said he feared people would be deterred from
going to the doctor’s.

“For the last two years only my wife was employed and not
earning much. If we needed to go to the hospital today, a
co-payment of 20 euros, instead of 2 euros as it was before,
plus the price of the drugs would take out a huge chunk of our
monthly family income,” he said.

Hospital executives and government officials brandish
statistics to rebut media reports that the death rate has
already started to climb because people can no longer afford all
the tablets and medicines they need.

But Pedro Pita Barros, an economics professor at the Nova
School of Business and Economics in Lisbon, said Portugal was
probably at the limit of how much patients could be expected to
pay out of their own pocket.

“You have people easily paying 40, 50, 60 percent of the
cost of their drugs, and some of these will be chronic
patients,” he said. “The only thing that has helped them is a
steep fall in price because of competition from generics;
otherwise they’d have faced a hard time.”

The government is expanding the use of cheaper generic drugs
at the behest of the troika. By the end of 2012, Portugal’s
pharmaceuticals bill will have dropped 20 percent, or 525
million euros, in two years to 1.25 percent of GDP, according to
Joao Almeida Lopes, chairman of Apifarma, the Portuguese
pharmaceutical association.

IN PORTUGAL’S GENETIC CODE

A brighter result of the debt crisis for the pharmaceutical
industry is that the government, again at the troika’s prodding,
finally intends to start paying next month about 3 billion euros
of arrears built up over the past decade or more in the NHS.

“When you work with public hospitals, you’re lucky to get
paid after a year,” said Ricardo Matos, an account manager at
Alere Inc, a U.S. medical diagnostics developer.

Apifarma says pharmaceutical providers alone were owed 1.39
billion euros at the end of February, with payments taking an
average of 500 days to come through. Some companies that were
owed money and starved of credit have had to close, Lopes said.

“Our greatest enemy is the systematic underbudgeting of the
health system in Portugal,” he said. “In terms of health care,
we should be careful not to go beyond what has been agreed with
the troika and is in the budget for 2012.”

That sounds self-serving, but Barros with the Nova School
said the government’s goal of cutting 1 billion euros from this
year’s budget of about 7.5 billion euros was probably too
ambitious.

Weighed against that judgment, the IMF has identified health
costs as the largest potential source of medium- and long-term
fiscal pressure for Portugal. In today’s money, the Fund
estimates the country’s future related health costs at 116
percent of GDP, dwarfing the average for advanced economies of
66 percent.

In other ways, though, Portugal is better placed than many
others. An OECD analysis of health efficiency in 30 of its
member states reckoned that only five countries had greater
potential than Portugal for savings in public health spending.
Portugal ranked above Denmark and Finland for efficiency in its
peer group.

Portugal has also grasped the nettle of pension reform by
linking payments to longevity. Moreover, its demographic profile
is less severe than that of many of its neighbours. As a result,
it faces one of the smallest rises in projected ageing costs in
the EU – 4 percentage points of GDP or less – between 2007 and
2060, according to a European Commission study.

As such, the task of caring for the old will be more a
matter of organisation than spending ever greater sums, said
Barros: “More elderly people living alone with chronic
conditions will require more health care in the community than
in hospitals.”

Still, the coming years will test health policymakers and
finance ministers, especially in countries such as Portugal
where the benefits of publicly-funded universal access to
medical care are taken for granted.

Jose Martins Nunes, head of a cluster of seven hospitals in
Coimbra, said asking the better-off to pay more would undo the
very fabric of the national health service.

“The situation is tough, but the NHS is part of Portugal’s
genetic code. We will do everything within our means to maintain
the model as it is,” he said.

(editing by David Stamp)

Copyright © 2012, Reuters