Estado, mercado e esporte: contribuições críticas ao debate / State, market and sport: critical contributions to the debate

No presente trabalho nos propomos a refletir sobre a necessidade da existência de uma estrutura ministerial para os esportes. Para isso, apresentamos um levantamento sobre a localização do tema na estrutura governamental de outros países, bem como buscamos comentar e responder às considerações e críticas formuladas por Dias (2020). A partir da análise dos fundamentos da dinâmica capitalista, concluímos que o mercado não é capaz de garantir o acesso igualitário e universal ao esporte, e afirmamos a presença estatal como necessária para o processo de superação do sistema vigente. Por fim, indicamos o risco que representa as narrativas conservadoras e a-históricas, que em nome de um mal menor, e de uma suposta temperança política, nos convidam a abandonar projetos de transformação radical e aceitar a dura realidade como a melhor ou a única possível.

In this paper we propose to reflect on the existence of a ministerial structure for sports. For this, we present data on this theme in the governmental structure of other countries, as well as seeking to comment and respond to the considerations and formulated by Dias (2020). From the analysis of the fundamentals of capitalist dynamics, we conclude that the market is not able to guarantee equal and universal access to sport, and we affirm the state presence as necessary for the process of overcoming the current system. Finally, we indicate the risk posed by conservative and unhistorical narratives, which in the name of one of supposed political temperance, invite us to abandon projects of radical transformation and accept the harsh reality as the best or the only possible one.

The Economic Promise of Delayed Aging.

Biomedicine has made enormous progress in the last half century in treating common diseases. However, we are becoming victims of our own success. Causes of death strongly associated with biological aging, such as heart disease, cancer, Alzheimer's disease, and stroke-cluster within individuals as they grow older. These conditions increase frailty and limit the benefits of continued, disease-specific improvements. Here, we show that a "delayed-aging" scenario, modeled on the biological benefits observed in the most promising animal models, could solve this problem of competing risks. The economic value of delayed aging is estimated to be $7.1 trillion over 50 years. Total government costs, including Social Security, rise substantially with delayed aging--mainly caused by longevity increases--but we show that these can be offset by modest policy changes. Expanded biomedical research to delay aging appears to be a highly efficient way to forestall disease and extend healthy life.

National mandatory motorcycle helmet laws may save $2.2 billion annually: An inpatient and value of statistical life analysis.

BACKGROUND: While statistics exist regarding the overall rate of fatalities in motorcyclists with and without helmets, a combined inpatient and value of statistical life (VSL) analysis has not previously been reported. METHODS: Statistical data of motorcycle collisions were obtained from the Centers for Disease Control, National Highway Transportation Safety Board, and Governors Highway Safety Association. The VSL estimate was obtained from the 2002 Department of Transportation calculation. Statistics on helmeted versus nonhelmeted motorcyclists, death at the scene, and inpatient death were obtained using the 2010 National Trauma Data Bank. Inpatient costs were obtained from the 2010 National Inpatient Sample. Population estimates were generated using weighted samples, and all costs are reported using 2010 US dollars using the Consumer Price Index. RESULTS: A total of 3,951 fatal motorcycle collisions were reported in 2010, of which 77% of patients died at the scene, 10% in the emergency department, and 13% as inpatients. Thirty-seven percent of all riders did not wear a helmet but accounted for 69% of all deaths. Of those motorcyclists who survived to the hospital, the odds ratio of surviving with a helmet was 1.51 compared with those without a helmet (p < 0.001). Total costs for nonhelmeted motorcyclists were 66% greater at $5.5 billion, compared with $3.3 billion for helmeted motorcyclists (p < 0.001). Direct inpatient costs were 16% greater for helmeted riders ($203,248 vs. $175,006) but led to more than 50% greater VSL generated (absolute benefit, $602,519 per helmeted survivor). CONCLUSION: A cost analysis of inpatient care and indirect costs of motorcycle riders who do not wear helmets leads to nearly $2.2 billion in losses per year, with almost 1.9 times as many deaths compared with helmeted motorcyclists. The per capita cost per fatality is more than $800,000. Institution of a mandatory helmet law could lead to an annual cost savings of almost $2.2 billion. LEVEL OF EVIDENCE: Economic analysis, level III.

Assessing whether there is a cancer premium for the value of a statistical life.

This article estimates whether there is a cancer risk premium for the value of a statistical life using stated preference valuations of cancer risks for a large, nationally representative US sample. The present value of an expected cancer case that occurs after a one decade latency period is $10.85m, consistent with a cancer premium that is 21% greater than the median value of a statistical life estimates for acute fatalities. This cancer premium is smaller than the premium proposed for policy analyses in the UK and the USA. There is also a greater premium for policies that reduce cancer risks to zero and for risk reductions affecting those who perceive themselves to have a greater than average probability of having cancer.

Economic modeling of surgical disease: a measure of public health interventions.

The measurement of the burden of disease and the interventions that address that burden can be done in various units. Reducing these measures to the common denominator of economic units (i.e., currency) enables comparison with other health entities, interventions, and even other fields. Economic assessment is complex, however, because of the multifactorial components of what constitutes health and what constitutes health interventions, as well as the coupling of those data to economic means. To perform economic modeling in a meaningful manner, it is necessary to: (1) define the health problem to be addressed; (2) define the intervention to be assessed; (3) define a measure of the effect of the health entity with and without the intervention (which includes defining the counterfactual); and (4) determine the appropriate method of converting the health effect to economics. This paper discusses technical aspects of how economic modeling can be done both of disease entities and of interventions. Two examples of economic modeling applied to surgical problems are then given.

Lost productivity due to premature mortality in developed and emerging countries: an application to smoking cessation.

BACKGROUND: Researchers and policy makers have determined that accounting for productivity costs, or "indirect costs," may be as important as including direct medical expenditures when evaluating the societal value of health interventions. These costs are also important when estimating the global burden of disease. The estimation of indirect costs is commonly done on a country-specific basis. However, there are few studies that evaluate indirect costs across countries using a consistent methodology. METHODS: Using the human capital approach, we developed a model that estimates productivity costs as the present value of lifetime earnings (PVLE) lost due to premature mortality. Applying this methodology, the model estimates productivity costs for 29 selected countries, both developed and emerging. We also provide an illustration of how the inclusion of productivity costs contributes to an analysis of the societal burden of smoking. A sensitivity analysis is undertaken to assess productivity costs on the basis of the friction cost approach. RESULTS: PVLE estimates were higher for certain subpopulations, such as men, younger people, and people in developed countries. In the case study, productivity cost estimates from our model showed that productivity loss was a substantial share of the total cost burden of premature mortality due to smoking, accounting for over 75 % of total lifetime costs in the United States and 67 % of total lifetime costs in Brazil. Productivity costs were much lower using the friction cost approach among those of working age. CONCLUSIONS: Our PVLE model is a novel tool allowing researchers to incorporate the value of lost productivity due to premature mortality into economic analyses of treatments for diseases or health interventions. We provide PVLE estimates for a number of emerging and developed countries. Including productivity costs in a health economics study allows for a more comprehensive analysis, and, as demonstrated by our illustration, can have important effects on the results and conclusions.

The social cost of adverse medical events, and what we can do about it.

Adverse medical events-medical interventions that cause harm or injury to a patient separate from the underlying medical condition-are unfortunately an all-too-frequent occurrence in US hospitals. They may cause as many as 187,000 deaths in hospitals each year, and 6.1 million injuries, both in and out of hospitals. We estimate the annual social cost of these adverse medical events based on what people are willing to pay to avoid such risks in non-health care settings. That social cost ranges from $393 billion to $958 billion, amounts equivalent to 18 percent and 45 percent of total US health care spending in 2006. A possible solution: Patients offered voluntary, no-fault insurance prior to treatment or surgery would be compensated if they suffered an adverse event-regardless of the cause of their misfortune-and providers would have economic incentives to reduce the number of such events.

How long and how well: oncologists' attitudes toward the relative value of life-prolonging v. quality of life-enhancing treatments.

OBJECTIVE: To determine how oncologists value quality-enhancing v. life-prolonging outcomes attributable to chemotherapy. METHODS: The authors surveyed a random sample of 1379 US medical oncologists (members of the American Society of Clinical Oncology), presenting them with 2 scenarios involving a hypothetical new chemotherapy drug. Given their responses, the authors derived the implicit cost-effectiveness ratios each physician attributed to quality-enhancing and life-prolonging chemotherapies. RESULTS: The authors received responses from 58% of the oncologists surveyed. On average, the responses implied that oncologists were willing to prescribe treatments that cost $245,972 per quality-adjusted life-year (QALY; SD $243,663 per QALY) in life-prolonging situations v. only $119,082 per QALY (SD $197,048 per QALY) for treatments that improve quality of life but do not prolong survival (P < 0.001). This difference did not depend on age, gender, percentage of time in clinical work, or self-reported preparedness to use and interpret cost-effectiveness information (P > 0.05 for all specifications). Differences across these situations persisted even among those who considered themselves to be "well-prepared" to make cost-effectiveness decisions. CONCLUSION: Cost-effectiveness thresholds for oncologists vary widely for life-prolonging chemotherapy compared to treatments that only enhance quality of life. This difference suggests that oncologists value length of survival more highly than quality of life when making chemotherapy decisions.

Toxic exposure in America: estimating fetal and infant health outcomes from 14 years of TRI reporting.

We examine the effect of exposure to a set of toxic pollutants that are tracked by the Toxic Release Inventory (TRI) from manufacturing facilities on county-level infant and fetal mortality rates in the United States between 1989 and 2002. Unlike previous studies, we control for toxic pollution from both mobile sources and non-TRI reporting facilities. We find significant adverse effects of toxic air pollution concentrations on infant mortality rates. Within toxic air pollutants we find that releases of carcinogens are particularly problematic for infant health outcomes. We estimate that the average county-level decreases in various categories of TRI concentrations saved in excess of 13,800 infant lives from 1989 to 2002. Using the low end of the range for the value of a statistical life that is typically used by the EPA of $1.8M, the savings in lives would be valued at approximately $25B.

An economic evaluation of the war on cancer.

For decades, the US public and private sectors have committed substantial resources towards cancer research, but the societal payoff has not been well-understood. We quantify the value of recent gains in cancer survival, and analyze the distribution of value among various stakeholders. Between 1988 and 2000, life expectancy for cancer patients increased by roughly four years, and the average willingness-to-pay for these survival gains was roughly $322,000. Improvements in cancer survival during this period created 23 million additional life-years and roughly $1.9 trillion of additional social value, implying that the average life-year was worth approximately $82,000 to its recipient. Health care providers and pharmaceutical companies appropriated 5-19% of this total, with the rest accruing to patients. The share of value flowing to patients has been rising over time. In terms of economic rates of return, R&D investments against cancer have been a success, particularly from the patient's point of view.

Cost-benefit analysis involving addictive goods: contingent valuation to estimate willingness-to-pay for smoking cessation.

The valuation of changes in consumption of addictive goods resulting from policy interventions presents a challenge for cost-benefit analysts. Consumer surplus losses from reduced consumption of addictive goods that are measured relative to market demand schedules overestimate the social cost of cessation interventions. This article seeks to show that consumer surplus losses measured using a non-addicted demand schedule provide a better assessment of social cost. Specifically, (1) it develops an addiction model that permits an estimate of the smoker's compensating variation for the elimination of addiction; (2) it employs a contingent valuation survey of current smokers to estimate their willingness-to-pay (WTP) for a treatment that would eliminate addiction; (3) it uses the estimate of WTP from the survey to calculate the fraction of consumer surplus that should be viewed as consumer value; and (4) it provides an estimate of this fraction. The exercise suggests that, as a tentative first and rough rule-of-thumb, only about 75% of the loss of the conventionally measured consumer surplus should be counted as social cost for policies that reduce the consumption of cigarettes. Additional research to estimate this important rule-of-thumb is desirable to address the various caveats relevant to this study.

Estimates and projections of value of life lost from cancer deaths in the United States.

BACKGROUND: Value-of-life methods are increasingly used in policy analyses of the economic burden of disease. The purpose of this study was to estimate and project the value of life lost from cancer deaths in the United States. METHODS: We estimated and projected US age-specific mortality rates for all cancers and for 16 types of cancer in men and 18 cancers in women in the years 2000-2020 and applied them to US population projections to estimate the number of deaths in each year. Cohort life tables were used to calculate the remaining life expectancy in the absence of cancer deaths-the person-years of life lost (PYLL). We used a willingness-to-pay approach in which the value of life lost due to cancer death was calculated by multiplying PYLL by an estimate of the value of 1 year of life ($150,000). We performed sensitivity analyses for female breast, colorectal, lung, and prostate cancers using varying assumptions about future cancer mortality rates through the year 2020. RESULTS: The value of life lost from all cancer deaths in the year 2000 was $960.6 billion; lung cancer alone represented more than 25% of this value. Projections for the year 2020 with current cancer mortality rates showed a 53% increase in the total value of life lost ($1472.5 billion). Projected annual decreases of cancer mortality rates of 2% reduced the expected value of life lost in the year 2020 from $121.0 billion to $80.7 billion for breast cancer, $140.1 billion to $93.5 billion for colorectal cancer, from $433.4 billion to $289.4 billion for lung cancer, and from $58.4 billion to $39.0 billion for prostate cancer. CONCLUSIONS: Estimated value of life lost due to cancer deaths in the United States is substantial and expected to increase dramatically, even if mortality rates remain constant, because of expected population changes. These estimates and projections may help target investments in cancer control strategies to tumor sites that are likely to result in the greatest burden of disease and to interventions that are the most cost-effective.

Start spreading the news: a structural estimate of the effects of New York hospital report cards.

Research on the effects of publicly reported hospital quality report cards on patient market shares is mixed. Higher-ranking hospitals do not consistently experience increases in market share. We argue that this may be because the report cards do not always convey "news" about quality; in some cases the rankings conform with prior beliefs about quality. We develop a structural model of the "news" in report cards and estimate the model using data from New York State in 1989-1991. We show hospitals with negative news in the original 1990 report cards experienced a decrease in market share, but that a misspecified model might continue to find no report card effect.

The mortality cost to smokers.

This article estimates the mortality cost of smoking using the first labor market estimates of the value of statistical life by smoking status. The value of statistical life is $7 million for both smokers and nonsmokers. Using this value in conjunction with the increase in the mortality risk over the life cycle due to smoking, the value of statistical life by age and gender, and information on the number of packs smoked over the life cycle, the private mortality cost of smoking is $222 per pack for men and $94 per pack for women in $2006, based on a 3% discount rate. At discount rates of 15% or more, the cost decreases to under $25 per pack.

Trastuzumab in early stage breast cancer: a cost-effectiveness analysis for Belgium.

OBJECTIVES: Although trastuzumab is traditionally used in metastatic breast cancer treatment, studies reported on the efficacy and safety of trastuzumab in adjuvant setting for the treatment of early stage breast cancer in HER2+ tumors. We estimated the cost-effectiveness and budget impact of reimbursing trastuzumab in this indication from a payer's perspective. METHODS: We constructed a health economic model. Long-term consequences of preventing patients to progress to metastatic breast cancer and side effects such as congestive heart failure were taken into account. Uncertainty was handled applying probabilistic modeling and through probabilistic sensitivity analyses. RESULTS: In the HERA scenario, applying an arbitrary threshold of euro30000 per life-year gained, early stage breast cancer treatment with trastuzumab is cost-effective for 9 out of 15 analyzed subgroups (according to age and stage). In contrast, treatment according to the FinHer scenario is cost-effective in 14 subgroups. Furthermore, the FinHer regimen is most of the times cost saving with an average incremental cost of euro668, euro-1045, and euro-6869 for respectively stages I, II and III breast cancer patients whereas the HERA regimen is never cost saving due to the higher initial treatment costs. CONCLUSIONS: The model shows better cost-effectiveness for the 9-week initial treatment (FinHer) compared to no trastuzumab treatment than for the 1-year post-chemotherapy treatment (HERA). Both from a medical and an economic point of view, the 9-week initial treatment regimen with trastuzumab shows promising results and justifies the initiation of a large comparative trial with a 1-year regimen.

Cost-effectiveness analysis of entecavir versus lamivudine in the first-line treatment of Australian patients with chronic hepatitis B.

BACKGROUND: Chronic hepatitis B (CHB) virus infection is a major global healthcare problem. The recent introduction of entecavir in Australia for the treatment of CHB patients in the naive treatment setting has triggered significant optimism with regards to improved clinical outcomes for CHB patients. OBJECTIVE: To estimate, from an Australian healthcare perspective, the cost effectiveness of entecavir 0.5 mg/day versus lamivudine 100 mg/day in the treatment of CHB patients naive to nucleos(t)ide therapy. METHODS: A cost-utility analysis to project the clinical and economic outcomes associated with CHB disease and treatment was conducted by developing two decision-tree models specific to hepatitis B e antigen-positive (HBeAg+ve) and HBeAg-ve CHB patient subsets. This analysis was constructed using the Australian payer perspective of direct costs and outcomes, with indirect medical costs and lost productivity not being included. The study population comprised a hypothetical cohort of 1000 antiviral treatment-naive CHB patients who received either entecavir 0.5 mg/day or lamivudine 100 mg/day at model entry. The population of patients used in this analysis was representative of those patients likely to receive initial antiviral therapy in clinical practice in Australia. The long-term cost effectiveness of entecavir compared with lamivudine in the first-line treatment of CHB patients was expressed as an incremental cost per life-year gained (LYG) or QALY gained. RESULTS: Results revealed that the availability of entecavir 0.5 mg/day as part of the Australian hepatologist's treatment armamentarium should result in significantly lower future rates of compensated cirrhosis (CC), decompensated cirrhosis (DC), and hepatocellular carcinoma (HCC) events (i.e. 54 fewer cases of CC, seven fewer cases of DC, and 20 fewer cases of HCC over the model's timeframe for HBeAg+ve CHB patients, and 69 fewer cases of CC, eight fewer cases of DC and 25 fewer cases of HCC over the model's timeframe for HBeAg-ve CHB patients). Compared with lamivudine 100 mg/day, entecavir 0.5 mg/day generated an estimated incremental cost per LYG of Australian dollars ($A, year 2006 values) 5046 and an estimated incremental cost per QALY of $A5952 in the HBeAg+ve CHB patient population, an estimated incremental cost per LYG of $A7063 and an estimated incremental cost per QALY of $A8003 in the HBeAg-ve CHB patient population, and an overall estimated incremental cost per LYG of $A5853 and an estimated incremental cost per QALY of $A6772 in the general CHB population. CONCLUSION: The availability of entecavir in Australian clinical practice should make long-term suppression of hepatitis B virus replication increasingly attainable, resulting in fewer CHB sequelae, at an acceptable financial cost.

How much are patients willing to pay to avoid postoperative muscle pain associated with succinylcholine?

STUDY OBJECTIVE: To determine how much money patients are willing to pay to avoid postoperative muscle pains associated with succinylcholine. DESIGN: Observational study with survey instrument. SETTING: University-affiliated metropolitan hospital. PATIENTS: Eighty-eight adult patients, 43 men and 45 women, who were scheduled to undergo surgery with general anesthesia and who completed a preoperative questionnaire (median age range, 41-50 y; median income, US$45,000-60,000). INTERVENTIONS AND MEASUREMENTS: Patients completed a computerized, interactive questionnaire preoperatively. They were asked about demographics and previous experiences with muscle pain and postoperative myalgia. With the use of the willingness-to-pay model, the value that they would be willing to pay for a hypothetical muscle relaxant that avoided postoperative myalgia was determined. MAIN RESULTS: Eighty-nine percent of patients considered avoiding postoperative myalgia as important. Patients were willing to pay a median (interquartile range) of $33 ($19-$50) out of pocket for a muscle relaxant that was not associated with postoperative myalgia, a figure that increased to $40 if the insurance company paid for the drug (P < 0.0001). Willingness to pay was influenced by patients' income but not by prior experience with postoperative myalgia. CONCLUSION: Patients consider avoidance of postoperative myalgia important and are willing to pay $33 out of pocket for a muscle relaxant that is not associated with this side effect.