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3.
Lancet ; 395(10223): 524-533, 2020 02 15.
Artículo en Inglés | MEDLINE | ID: mdl-32061298

RESUMEN

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.


Asunto(s)
Prestación de Atención de Salud/organización & administración , Ahorro de Costo/métodos , Prestación de Atención de Salud/economía , Costos de los Medicamentos/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Medicare/economía , Patient Protection and Affordable Care Act , Pronóstico , Estados Unidos
4.
BMJ ; 368: m40, 2020 Feb 05.
Artículo en Inglés | MEDLINE | ID: mdl-32024637

RESUMEN

OBJECTIVE: To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN: Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING: United States. PARTICIPANTS: A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES: Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS: 37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION: Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.


Asunto(s)
Financiación Personal/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Renta/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Medicaid/legislación & jurisprudencia , Pobreza/economía , Pobreza/estadística & datos numéricos , Adulto , Costo de Enfermedad , Femenino , Financiación Personal/economía , Gastos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Encuestas Epidemiológicas , Humanos , Cobertura del Seguro/economía , Masculino , Medicaid/economía , Persona de Mediana Edad , Estados Unidos/epidemiología
8.
Einstein (Sao Paulo) ; 18: eGS5129, 2020.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31939526

RESUMEN

OBJECTIVE: Economic evaluation of a scientific advisory program with the Public Defenders Office to mitigate the impacts of the judicialization on health in the municipality, as well as the implementation of an active follow-up program to monitor health outcomes arising from court demands. METHODS: A two-step study, the first documental, retrospective, with data collection of lawsuits in the region of Barbalha (CE), Brazil, from 2013 to 2018, and the second stage, prospective and intervention, through mediation between the citizen and the Public Defenders Office, aiming to reduce the occurrence of the judicialization, and the monitoring of the health outcomes of the processes. The study adopted the Consolidated Health Economic Evaluation Reporting Standards protocol for economic health assessments. The data obtained from the processes were grouped and treated for characterization of the scenario. A comparison of the profile of the lawsuits in the period of 12 months before and after the installation of the program to delimit a complete fiscal cycle was carried out. RESULTS: The advisory service promoted a decrease of 40% (p=0.01) in lawsuits. There was a 31% reduction in court costs (p=0.003), with medicines accounting for 33% of this amount. There was a decrease in inputs outside the Sistema Único de Saúde lists (27%; p=0.003), however there was no statistical difference among several demanding groups, suggesting an equanimous approach. CONCLUSION: Data from the initial survey were comparable to those reported in Brazil regarding the profile of judicial demands. In view of the scenario, the proposal proved feasible as a means to mitigate the costs of the judicialization through mediation. Finally, the initiative can serve as a model for adoption by municipalities that have characteristics similar to those presented in this study.


Asunto(s)
Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Necesidades y Demandas de Servicios de Salud/legislación & jurisprudencia , Rol Judicial , Brasil , Ciudades , Costos de la Atención en Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud/economía , Humanos , Programas Nacionales de Salud/legislación & jurisprudencia , Estudios Retrospectivos , Factores Socioeconómicos
10.
Arthritis Care Res (Hoboken) ; 72(2): 208-215, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31562794

RESUMEN

OBJECTIVE: To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion. METHODS: A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition. RESULTS: There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges. CONCLUSION: Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.


Asunto(s)
Accesibilidad a los Servicios de Salud/tendencias , Precios de Hospital/tendencias , Hospitalización/tendencias , Lupus Eritematoso Sistémico/epidemiología , Medicaid/tendencias , Patient Protection and Affordable Care Act/tendencias , Adulto , Femenino , Accesibilidad a los Servicios de Salud/economía , Hospitalización/economía , Humanos , Análisis de Series de Tiempo Interrumpido/economía , Análisis de Series de Tiempo Interrumpido/tendencias , Lupus Eritematoso Sistémico/economía , Lupus Eritematoso Sistémico/terapia , Masculino , Medicaid/economía , Persona de Mediana Edad , Patient Protection and Affordable Care Act/economía , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto Joven
11.
J Surg Res ; 246: 93-99, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31562991

RESUMEN

BACKGROUND: Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda. METHODS: A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach. RESULTS: For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system. CONCLUSIONS: Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.


Asunto(s)
Costo de Enfermedad , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Hospitales Pediátricos/estadística & datos numéricos , Enfermedades del Recién Nacido/cirugía , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Análisis Costo-Beneficio , Femenino , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/economía , Fuerza Laboral en Salud/economía , Fuerza Laboral en Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitales Pediátricos/economía , Humanos , Recién Nacido , Enfermedades del Recién Nacido/economía , Enfermedades del Recién Nacido/epidemiología , Masculino , Estudios Prospectivos , Años de Vida Ajustados por Calidad de Vida , Procedimientos Quirúrgicos Operativos/economía , Tasa de Supervivencia , Uganda/epidemiología
13.
Einstein (Sao Paulo) ; 18: eGS4442, 2020.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31576910

RESUMEN

OBJECTIVE: To analyze the legal demands of tiotropium bromide to treat chronic obstructive pulmonary disease. METHODS: We included secondary data from the pharmaceutical care management systems made available by the Paraná State Drug Center. RESULTS: Public interest civil action and ordinary procedures, among others, were the most common used by the patients to obtain the medicine. Two Health Centers in Paraná (Londrina and Umuarama) concentrated more than 50% of the actions. The most common specialty of physicians who prescribed (33.8%) was pulmonology. There is a small financial impact of tiotropium bromide on general costs with medicines of the Paraná State Drug Center. However, a significant individual financial impact was observed because one unit of the medicine represents 38% of the Brazilian minimum wage. CONCLUSION: Our study highlights the need of incorporating this medicine in the class of long-acting anticholinergic bronchodilator in the Brazilian public health system.


Asunto(s)
Broncodilatadores/economía , Medicamentos Esenciales/provisión & distribución , Necesidades y Demandas de Servicios de Salud/legislación & jurisprudencia , Rol Judicial , Enfermedad Pulmonar Obstructiva Crónica/economía , Bromuro de Tiotropio/economía , Brasil , Medicamentos Esenciales/economía , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/tendencias , Necesidades y Demandas de Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud/tendencias , Humanos , Programas Nacionales de Salud , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Estudios Retrospectivos , Estadísticas no Paramétricas , Factores de Tiempo
14.
J Surg Res ; 245: 629-635, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31522036

RESUMEN

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Asunto(s)
Tratamiento de Urgencia/efectos adversos , Disparidades en Atención de Salud/economía , Renta/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adolescente , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Pacientes Internos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Población Rural/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos , Adulto Joven
16.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 749-753, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31825682

RESUMEN

Background: Agreements between payers and pharmaceutical/medical device companies are widely implemented to address financial and clinical uncertainties. We analyzed the main characteristics of these agreements in Israel from 2011-2018.Research design and methods: We reviewed all agreements implemented during the study period. Information regarding the type of agreement, therapeutic indications, its time frame and the total budget involved are presented.Results: A total of 56 agreements were signed since 2011, of which 53 (95%) were financial-based and 50 (89%) referred to pharmaceuticals. The annual number of agreements increased from one in 2011 to 21 in 2018. The main therapeutic areas covered were: oncology (41%), hepatitis C (16%), neurology (11%), respiratory (9%), and cardiovascular (7%). The proportion of the annual budget allocated subject to these agreements increased accordingly from 3% in 2011 to 73% in 2018. The majority (63%) of the agreements were signed for 5 years, 9% were shorter-term and 20% have no time-limit. In 14 (44%) of the financial-based agreements implemented through 2017, the actual utilization exceeded the pre-specified threshold and the companies reimbursed the health-plans accordingly.Conclusions: The number of agreements and the allocated budget subject to these agreements increased substantially in recent years. Most agreements are financial-based that, in many cases, shifted the short-term financial risk from health-plans to the industry.


Asunto(s)
Industria Farmacéutica/organización & administración , Accesibilidad a los Servicios de Salud/economía , Programas Nacionales de Salud/organización & administración , Prorrateo de Riesgo Financiero/organización & administración , Presupuestos , Industria Farmacéutica/economía , Servicios de Salud/economía , Humanos , Israel , Programas Nacionales de Salud/economía , Mecanismo de Reembolso/economía , Prorrateo de Riesgo Financiero/economía , Incertidumbre
17.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 627-632, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31810392

RESUMEN

Introduction: There is significant difference in utilization of patented medicines in the EU, as pharmaceuticals at Western European price levels are usually not cost-effective in Central and Eastern European (CEE) countries. The article reviews options to solve the 'financing gap' posed by the challenge of covering patented medicines from more restricted resources in countries with greater unmet medical need.Areas covered: Hidden volume restrictions to patented pharmaceuticals implemented by payers to facilitate financial sustainability may increase European inequity in patient access. Confidential price discounts and financial risk-sharing agreements improve cost-effectiveness of pharmaceuticals with limited impact on the European floor price. Narrowing the eligible group of patients on the positive drug list can help to target the medicines to patients with potentially greater health benefit whilst reducing the budget impact. Pay-for-performance schemes can improve cost-effectiveness of pharmaceuticals with significant uncertainty or heterogeneity in the magnitude of added therapeutic value. Increased utilization of off-patent pharmaceuticals can increase patient access through re-investing the savings from generic or biosimilar price erosion.Expert opinion: Transparent and sustainable pharmaceutical policies aiming to improve the allocative efficiency of scarce resources should be implemented in CEE to reduce financing gap and improve patient access to high-cost medicines.


Asunto(s)
Costos de los Medicamentos/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Preparaciones Farmacéuticas/provisión & distribución , Reembolso de Incentivo/economía , Análisis Costo-Beneficio , Control de Medicamentos y Narcóticos , Economía Farmacéutica , Unión Europea , Humanos , Patentes como Asunto , Preparaciones Farmacéuticas/economía , Prorrateo de Riesgo Financiero/economía
18.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 717-723, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31826655

RESUMEN

Objectives: Timely access to novel anticancer drugs is challenging and value frameworks such as the European Society of Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) could assist in drug prioritization. We assessed the overall time to access to novel anticancer drugs in Slovenia and its correlation with ESMO-MCBS scores.Methods: Anticancer drugs with European Medicines Agency marketing authorization (EMA MA), applying for national reimbursement approval (NRA) in the period 2008-2018 with assigned ESMO-MCBS score, were included. Publically available data from EMA and the Slovenian National Health Insurance Institute were used for time calculations.Results: Among 53 studied drugs; a majority (47) of them obtained reimbursement approval within the observed time. The median time to EMA MA was 397 (range 98-615) days with the NRA requiring additional 422 (range 154-892) days. Neither time to EMA MA nor NRA correlated with ESMO-MCBS substantial clinical benefit (p = 0.332 and p = 0.965, respectively).Conclusions: In Slovenia, time to access to novel anticancer drugs exceeds two years and, more importantly, is equally long for drugs with or without substantial clinical benefit. Integration of the ESMO-MCBS into reimbursement deliberations could improve access to drugs with substantial clinical benefit.


Asunto(s)
Antineoplásicos/provisión & distribución , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Mecanismo de Reembolso/economía , Antineoplásicos/economía , Accesibilidad a los Servicios de Salud/economía , Humanos , Neoplasias/tratamiento farmacológico , Eslovenia , Sociedades Médicas , Factores de Tiempo
19.
J Bras Pneumol ; 45(6): e20180355, 2019.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31851214

RESUMEN

OBJECTIVE: A resolution passed by the government of the Brazilian state of São Paulo established a protocol for requesting free COPD medications, including tiotropium bromide, creating regional authorization centers to evaluate and approve such requests, given the high cost of those medications. Our objective was to analyze the requests received by an authorization center that serves cities in the greater metropolitan area of (the city of) São Paulo between 2011 and 2016. METHODS: Data regarding the authorization, return, or rejection of the requests were compiled and analyzed in order to explain those outcomes. Subsequently, the clinical and functional data related to the patients were evaluated. RESULTS: A total of 7,762 requests for dispensing COPD medication were analyzed. Requests related to male patients predominated. Among the corresponding patients, the mean age was 66 years, 12% were smokers, 88% had frequent exacerbations, and 84% had severe/very severe dyspnea. The mean FEV1 was 37.2% of the predicted value. The total number of requests decreased by 24.5% from 2012 to 2013 and was lowest in 2015. Most (65%) of the requests were accepted. The main reasons for the rejection/return of a request were a post-bronchodilator FEV1/FVC ratio > 0.7, a post-bronchodilator FEV1 > 50% of the predicted value, and failure to provide information regarding previous use of a long-acting ß2 agonist. During the study period, the total number of requests returned/rejected decreased slightly, and there was improvement in the quality of the data included on the forms. CONCLUSIONS: Here, we have identified the characteristics of the requests for COPD medications and of the corresponding patients per region served by the authorization center analyzed, thus contributing to the improvement of local public health care measures.


Asunto(s)
Broncodilatadores/economía , Broncodilatadores/provisión & distribución , Enfermedad Pulmonar Obstructiva Crónica/economía , Bromuro de Tiotropio/economía , Bromuro de Tiotropio/provisión & distribución , Anciano , Brasil , Costos de los Medicamentos/estadística & datos numéricos , Femenino , Volumen Espiratorio Forzado , Accesibilidad a los Servicios de Salud/economía , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Factores de Tiempo , Capacidad Vital/fisiología
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