Qual família e qual comunidade? Reconfigurações da Medicina de Família e Comunidade na saúde suplementar / ¿Qué familia y qué comunidad? Reconfiguraciones de la Medicina Familiar y Comunitaria en salud complementaria / Which family and which community? Reconfigurations of Family and Community Medicine in supplementary health

RESUMO: Trata-se de um estudo cartográfico que buscou analisar a atuação de médicos(as) de família e comunidade na Atenção Primária da saúde suplementar, realizado por meio de diários e entrevistas cartográficas entre março de 2021 e janeiro de 2022, processados semanalmente em reuniões de pesquisa. Tal estudo se deu com base nos analisadores: 'território', 'família' e 'comunidade'. Notou-se que a territorialização e a abordagem familiar ganham outros contornos na Medicina de Família e Comunidade praticada na saúde suplementar. Além disso, verificou-se que algumas das ferramentas típicas da Atenção Básica - como visita domiciliar, educação em saúde, genograma, ecomapa e vigilância em saúde - não eram utilizadas na atenção suplementar ou tiveram outras aplicabilidades dissonantes do modelo preconizado. Concluiu-se que a Medicina de Família e Comunidade na saúde suplementar se aproxima de uma atuação mais clínica, com perda da potência das linhas de força que constituem tal especialidade, tendendo a uma medicina menos familiar e comunitária.

RESUMEN: Se trata de un estudio cartográfico que buscó analizar el desempeño de los médicos de familia y comunidad en atención primaria de salud complementaria, realizado a través de diarios y entrevistas cartográficas entre marzo de 2021 y enero de 2022, que fueron procesados semanalmente en reuniones de investigación. Este estudio se basó en los analizadores: 'territorio', 'familia' y 'comunidad'. Se observó que la territorialización y el enfoque familiar adquieren otros contornos en la Medicina Familiar y Comunitaria practicada en salud complementaria. Además, se encontró que algunas de las herramientas típicas de la atención básica, como las visitas domiciliarias, la educación sanitaria, el genograma, el ecomap y la vigilancia sanitaria, no se utilizaron en la atención complementaria o tenían otra aplicabilidad disonante del modelo recomendado. Se concluyó que la Medicina Familiar y Comunitaria en salud complementaria se aproxima a una práctica más clínica, con pérdida de potencia de las líneas eléctricas que constituyen dicha especialidad, tendiendo a una medicina menos familiar y comunitaria.

ABSTRACT: This is a cartographic study that sought to analyze the performance of family and community physicians in primary care of supplementary health, carried out through diaries and cartographic interviews between March 2021 and January 2022, which were weekly processed in research meetings. This study was based on the analyzers: 'territory', 'family' and 'community'. It was noticed that territorialization and family approach gain other contours in Family and Community Medicine practiced in supplementary health. In addition, it was found that some of the typical tools of basic care - such as home visits, health education, genogram, ecomap and health surveillance - were not used in supplementary care or had other dissonant applicabilities of the recommended model. It was concluded that Family and Community Medicine in supplementary health approaches a more clinical practice, with loss of power from the power lines that constitute such specialty, tending to a less familiar and community medicine.

A produção científica em economia política no tema saúde suplementar e planos de saúde no Brasil entre 2004-2012 / Scientific production in political economy in complementary health and health insurance plans in Brazil between 2004-2012

A produção acadêmica na área da economia da saúde é um segmento da economia pouco explorado pelos profissionais de saúde, talvez pelo desconhecimento teórico ou pela falta de interesse desses profissionais em se aprofundar nesta área de conhecimento. No entanto, há uma importante produção acadêmica nesta área, e para nortear esse trabalho, fizemos uso da clássica obra de economia de saúde política de Braga e Paula (1981). Contudo, os artigos elaborados nesse campo estão majoritariamente alicerçados em fundamentos da teoria econômica neoclássica. É importante salientar que os autores neoclássicos recusam a economia como ciência social, pois, negam a complexidade das interações sociais com sua visão tecnicista, baseada em modelos abstratos que não consideram a história e as relações humanas. Portanto, o objetivo desse trabalho é caracterizar a produção de conhecimento da economia da saúde no Brasil, delimitando a discussão existente no contexto da economia política, particularmente nas temáticas de Saúde suplementar e Planos de Saúde. Para tanto, o trabalho está organizado em três partes. A primeira apresenta o campo da economia política e sua relação com a economia da saúde, baseado na contribuição sobre o pensamento econômico em Braga e Paula. A segunda, revisa a produção do conhecimento em economia da saúde, organizada pela Associação Brasileira de Economia da Saúde (Abres), entre 2004 a 2012, que descreve as temáticas da Saúde Suplementar e dos Planos de Saúde, verificando sua relação com a economia política. A terceira parte analisa criticamente as convergências e divergências entre a produção do conhecimento da economia da saúde, nos subtemas saúde suplementar e planos de saúde e as contribuições de Braga e Paula sobre o pensamento econômico da economia política da saúde. Nessa análise global, identificamos que o pensamento neoclássico e liberal permanecerá hegemônico entre os autores e economistas que se aventuram pelo campo da economia da saúde enquanto à matriz curricular dos cursos de economia for alicerçada por conteúdo produzido por autores neoclássicos.

The academic production in the area of health economics is a segment of the economy little explored by health professionals, perhaps due to the lack of theoretical knowledge and minimum interest of these professionals to deepen your own knowledge in this field. However, we used an important academic production in this area as the classic work of economics of political health wrote by Braga and Paula (1981). The articles elaborated in the field of health economy are mostly based on the foundations of neoclassical economic theory. It is important to point out that neoclassical authors reject economics as a social science because they deny the complexity of social interactions with their technicist view, based on abstract models that do not consider history and human relations. Therefore, the objective of this work is to characterize the production of knowledge of health economics in Brazil, delimiting the existing discussion in the context of political economy, particularly in the themes of Supplementary Health and Health Plans. For this, the dissertation is organized in three parts. The first part of this dissertation presents the field of political economy and its relationship with the health economy, based on the contribution on economic thinking in Braga and Paula. The second part is a review of the production of knowledge in health economics, organized by the Brazilian Association of Health Economics (Abres), between 2004 and 2012, which describes the themes of Supplementary Health and Health Plans, verifying their relationship with political economy. During the third and last part, we critically analyzes the convergences and divergences between the production of knowledge of health economics, in the subthemes supplementary health and health plans and the contributions of Braga and Paula on the economic thinking of the political economy of health. In this global analysis, we have identified that neoclassical and liberal thinking will remain hegemonic among authors and economists into the field of health economics while the economy graduation courses remain based in models and material produced by neoclassic authors.

Desigualdades sociodemográficas e na assistência à maternidade entre puérperas no Sudeste do Brasil segundo cor da pele: dados do inquérito nacional Nascer no Brasil (2011-2012) / Sociodemographic inequalities and maternity care of puerperae in Southeastern Brazil, according to skin color: data from the Birth in Brazil national survey (2011-2012)

Resumo Historicamente, no Brasil, os indicadores de saúde de mães e bebês segundo cor da pele mostram quadro desfavorável às negras (pretas e pardas). Na última década, a redução das disparidades de renda e escolaridade, assim como a universalização da assistência à saúde, podem ter alterado esse quadro, em alguma medida. O objetivo deste artigo foi analisar as mudanças nas desigualdades sociodemográficas e na assistência à maternidade no Sudeste do Brasil, segundo raça/cor, na última década. Utilizamos dados do inquérito nacional Nascer no Brasil (2011-2012). Análise estatística descritiva foi realizada para a caracterização sociodemográfica, do acesso à assistência pré-natal, antecedentes clínicos e obstétricos, e características da assistência ao parto. Encontramos diferenças desfavoráveis às pretas e pardas quanto à escolaridade, renda e ao trabalho remunerado; as brancas tinham mais planos de saúde privados e maior idade. As pretas e pardas tiveram menor número de consultas, menos ultrassonografias, mais cuidado pré-natal considerado inadequado, maior paridade e mais síndromes hipertensivas. No parto, tiveram menos acompanhantes, mais partos vaginais, embora a cesárea tenha dobrado entre as negras, que com mais frequência entraram em trabalho de parto e tiveram filhos nascidos de termo pleno. Não houve diferença estatisticamente significativa quanto à situação conjugal, intercorrências da gestação, diabetes mellitus, anemias, sífilis, HIV, peregrinação para o parto, near miss materno ou neonatal e na maioria das intervenções no parto vaginal. Ainda que importantes disparidades persistam, houve alguma redução das diferenças sociodemográficas e um aumento do acesso, tanto a intervenções adequadas quanto às desnecessárias e potencialmente danosas.

Abstract Historically, in Brazil, the health indicators of mothers and babies by skin color show an unfavorable picture to black and brown-skinned women. In the last decade, the reduction of disparities in income and education, as well as the universalization of health care, may have altered this situation to some extent. The objective of this study was to analyze the changes in socio-demographic inequalities and maternity care in Southeastern Brazil, by race/color, in the last decade. We used data from the national survey Born in Brazil (2011-2012). Descriptive statistical analysis was performed in order to define socio-demographic characteristics, access to antenatal care, clinical and obstetric history, and characteristics of birth assistance. We found differences unfavorable to black and brown-skinned women in education, income, and paid work; white women had more private health insurance plans, and increased age. Black and brown women had fewer medical appointments, fewer ultrasounds, more antenatal care considered inadequate, higher parity, and more hypertensive disorders. In childbirth, they had fewer companions and more vaginal deliveries, although the cesarean rate has grown twice as high among black women. More often they went into labor and had children born full term. There was no statistically significant difference in marital status, pregnancy complications, diabetes mellitus, anemia, syphilis, HIV, pilgrimage to delivery, neonatal or maternal near miss, and most of the interventions in vaginal delivery. Although major disparities persist, there was some reduction in sociodemographic differences as well as increased access to both appropriate and unnecessary and potentially harmful interventions.

As vantagens do atendimento homeopático em uma operadora de planos de saúde do sistema UNIMED do Estado de São Paulo

O presente trabalho tem como objetivo propor, através desta pesquisa empírica, os dados frente à realidade dos custos do atendimento homeopático em empresa cooperativa do sistema de saúde suplementar, baseado em levantamento referente ao período de 3 anos, 2009,2010 e 2011. Para viabilização do projeto, foi feito levantamento dos dados em empresa do sistema Unimed, com base em informações fornecidas pelo setor da ´´ Matriz Gerencial``, para comparar os custos referentes à utilização do tratamento homeopático com os custos da clínica médica e da operadora como um todo. Por outro lado, foi possível observar através de outros indicadores, aspectos que tem impacto econômico, como por exemplo, taxa retorno das consultas realizadas, taxa de procura por outros especialistas ou por outros médicos da mesma especialidade. A partir daí, e com fundamentação teórica adquirida do estudo bibliogrãfico, se fez a formalização da proposta.

Price vs. quantity in health insurance reimbursement.

While "integrated" systems regulate the quantity of health services, "Bismarckian" systems regulate their price. This paper compares the consumers' allocations implemented within the two reimbursement systems. In the model, illness has a negative impact on labor productivity while public insurance is financed through income tax. Consumers have private information with respect to a parameter which can be interpreted as heterogeneity either in intensity of their preferences for treatment or in the type of illness. The social planner may be constrained to adopt uniform insurance plans, or may be free to choose self selecting plans. The analysis of uniform plans shows that Bismarckian systems dominate integrated systems from the social welfare point of view; whereas the opposite ranking holds with self-selecting plans.

Use of e-Health services between 1999 and 2002: a growing digital divide.

OBJECTIVE: To evaluate the patterns of e-Health use over a four-year period and the characteristics of users. DESIGN: Longitudinal, population-based study (1999-2002) of members of a prepaid integrated delivery system. Available e-Health services included ordering prescription drug refills, scheduling appointments, and asking medical questions. MEASUREMENTS: Rates of known access to e-Health services, and of e-Health use each quarter. RESULTS: The number of members with known e-Health access increased from 51,336 (1.6%) in 1999 to 324,522 (9.3%), in 2002. The percentage of households in which at least one person in the household had access increased from 2.7% to 14.1%. Among the subjects with known access, the percentage of subjects that used e-Health at least once increased from 25.7% in 1999 to 36.2% in 2002. In the multivariate analysis, subjects who had a low expected clinical need, were nonwhite, or lived in low socioeconomic status (SES) neighborhoods were less likely to have used e-Health services in 2002. Disparities by race/ethnicity and SES persisted after controlling for access to e-Health and widened over time. CONCLUSION: Access to and use of e-Health services are growing rapidly. Use of these services appears to be greatest among persons with more medical need. The majority of subjects, however, do not use any e-Health services. More research is needed to determine potential reasons for disparities in e-Health use by race/ethnicity and SES as well as the implications of these disparities on clinical outcomes.

Financial risk management of pharmacy benefits.

Financial risk management of pharmacy benefits in integrated health systems is explained. A managed care organization should assume financial risk for pharmacy benefits only if it can manage the risk. Horizontally integrated organizations often do not have much control over the management of drug utilization and costs. Vertically integrated organizations have the greatest ability to manage pharmacy financial risk; virtual integration may also be compatible. Contracts can be established in which the provider is incentivized or placed at partial or full risk. The main concerns that health plans have with respect to pharmacy capitation are formulary management and the question of who should receive rebates from manufacturers. The components needed to managed pharmacy financial risk depend on the type of contract negotiated. Health-system pharmacists are uniquely positioned to take advantage of opportunities opening up through pharmacy risk contracting. Functions most organizations must provide when assuming pharmacy financial risk can be divided into internal and external categories. Internally performed functions include formulary management, clinical pharmacy services and utilization management, and utilization reports for physicians. Functions that can be outsourced include claims processing and administration, provider- and customer support services, and rebates. Organizations that integrate the pharmacy benefit across the health care continuum will be more effective in controlling costs and improving outcomes than organizations that handle this benefit as separate from others. Patient care should not focus on payment mechanisms and unit costs but on developing superior processes and systems that improve health care.

Fulfilling the sisters' promise. The heritage of healthcare's early days.

Members of religious orders--the sisters--built not just Catholic healthcare, but healthcare in America. A good 50 years before Henry and Edgar Kaiser got the idea, prepaid capitated health insurance was being offered by sisters who looked at what was needed and realized this was simply the best way to get it done. The sisters also created the integrated healthcare system at a time when the emerging medical elite wanted nothing to do with any patient who was not socially acceptable and potentially curable. They arranged a continuum of care for the aging sisters within their own communities. And they understood the concept of social medicine, of population-based healthcare, of healthy communities, long before these ideas became commonplace. But the sisters are gone, most of them. The question today is, How do we preserve the sisters' heritage and transfer it to a new millennium, a new healthcare system, and a new set of rules? First, it is important to understand that much of what we remember the sisters for--courage, compassion, vision-was not unique. They created many of the structures that today are the new models; but they were not alone. However, three aspects of how they expressed their vision and their faith were unique to the sisters and must be understood by those who wish to treat the path the sisters blazed. The purity of their commitment and its underlying philosophy--that the helpless and the sick must always be the point of the exercise--should pervade Catholic healthcare to its soul. These women, living in poverty, represented, and still represent, a singular group: a group of women who, having told the world that their only wish is to serve others, humble became CEOs of vast systems and trustees of huge enterprises, without ever abandoning that simple, original pledge. Although they bowed to the rule of obedience, and they were humble, the were fighters. They spoke out against poverty, bigotry, the shunning of those with certain diseases, lack of access to healthcare, stupidity, ignorance, and hate.

Quality assurance for a program of comprehensive care for older persons.

Quality assurance (QA) for comprehensive programs like the Program of All-inclusive Care for the Elderly (PACE) requires a special strategy. The assessment phase should be capable of looking across the usual subdivisions of care to recognize the contributions of various disciplines, and to focus on the effects of that care on the patient. Measures should thus include both problem-specific and patient-focused elements. The tracer technique which follows the care of specific problems provides an opportunity to look at both the process and outcomes of care. An outcomes focus which looks at patient functioning as well as condition-specific parameters can include specific sentinel events whose presence suggests untoward developments. Quality assurance implies more than assessment. It represents a commitment to act responsibly on the information obtained to improve the care rendered. It includes a strategy for proactive involvement where caregivers are prompted to consider pertinent information in a timely fashion, and a retrospective remedial approach where the data are analyzed and presented in a format that can be readily understood and which suggests next steps to improve care.