Costos médicos directos de la atención médica de pacientes con cáncer de mama / Direct medical costs in a cohort of patients with breast cancer

Introducción: el costo económico del tratamiento de cáncer de mama (CM) y el aumento en su incidencia y prevalencia desafía la estabilidad financiera de cualquier sistema de salud. Objetivo: determinar los costos médicos directos (CMD) del tratamiento de CM y los factores asociados a estos costos. Material y métodos: evaluación económica parcial en una cohorte retrospectiva de 160 pacientes con diagnóstico conf irmado de CM. Se consideraron CMD desde la perspectiva del IMSS. Se utilizó análisis de bootstrapping para tratar incertidumbre y el modelo lineal generalizado para identificar factores asociados a costos. Resultados: el costo promedio anual (CPA) del tratamiento de CM fue de $ 251,018 pesos. En estadio 1, $ 116,123; estadio II, $ 242,132; estadio III, $ 287,946, y estadio IV, $ 358,792 pesos. El CPA fue mayor en progresión del CM ($ 380,117 frente a no progresión $ 172,897), y en pacientes que fallecieron durante el seguimiento ($ 357,579) frente a aquellas que sobrevivieron ($ 218,699). Conclusiones: el CPA del tratamiento de CM fue de $ 251,018 pesos. Los CMD aumentan significativamente conforme las pacientes presentan estadios más avanzados de la enfermedad. Los factores asociados al CMD fueron edad, estadios II, III y la progresión del CM.

Background: The economic cost of breast cancer (BC) treatment and the increase in incidence and prevalence challenges the financial stability of any healthcare system. Objective: To determine direct medical costs (DMC) of BC treatment and factors associated with DMC. Material and methods: Partial economic evaluation in a retrospective cohort of 160 patients with a confirmed diagnosis of BC. DMC was considered from the IMSS perspective. Bootstrapping analysis was used to deal with uncertainty and generalized linear model to identify factors associated with DCM Results: The total average annual cost of BC treatment was $251,018 mexican pesos. In clinical stage I was $116,123, stage II $242,132, stage III $287,946, and stage IV $358,792 pesos. In progression disease, DMC were more elevate ($380,117) vs. without progression ($172,897), (p < 0.0001). In patients who died, DMC were $357,579 mexican pesos compared to those who survived ($218,699) (p < 0.0001). Conclusions: The average annual cost of CM treatment was $251,018 pesos. DMCs increase significantly as patients present more advanced stages of the disease. Factors associated with costs were age, stages II, III and the progression of BC.

Economic Impact of Schizophrenia from a Hospital and Social Security System Perspective in Italy.

BACKGROUND: Schizophrenia is one of the mental disorders with the highest economic and social costs, with an important burden on patients, caregivers, and society. OBJECTIVE: The objective of this study was to estimate the direct and social security costs of schizophrenia in Italy. As far as direct costs are concerned, those related to hospitalizations and pharmaceutical expenditure have been analyzed, while disability benefits (DBs) and incapacity pensions (IPs) have been considered for the social security costs. METHODS: In order to provide annual economic burden of schizophrenia using the real-world data, we analyzed the main regional and national databases related to hospitalizations and pharmaceuticals. Hospitalizations have been analyzed considering the Hospital Information System, which collects all the information regarding hospital discharges from all public and private hospitals (psychiatric wards or residential facilities have not been considered). Hospitalizations with a discharge date between 2009 and 2016, and with a primary or secondary diagnosis of schizophrenia (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 295.xx) were selected. Hospital costs have been estimated considering the national tariffs associated with each selected hospitalization. In addition, using the same inclusion criteria, the average DBs (for workers with reduced working capacity) and IPs (for workers without working capacity) provided each year have been analyzed from the social security benefit applications database. The estimate of pharmaceutical expenditure was prepared based on the OsMed 2018 Report (Italian Medicines Agency, latest issue 18 July 2019). A one-way deterministic sensitivity analysis was conducted to examine the robustness of the results. RESULTS: In Italy from 2009 to 2016, schizophrenia had an important economic impact from a social perspective. On average, 13,800 patients were hospitalized, with an average of 2.98 hospitalizations per patient. From a National Health Service (NHS) perspective and with specific reference to hospitalizations, the annual economic burden was €101.4 million, with an average cost per patient of €7338. On the other hand, pharmaceutical expenditure amounts to over €147 million each year, while residential, semi-residential, and specialist facilities amount to approximately €1 billion. Again, schizophrenia led to approximately 15,000 recipients of social security benefits (DBs and IPs) yearly from 2009 to 2015, with an average annual expenditure of €160.1 million (average cost per patient = €10,675). CONCLUSIONS: Our study estimates an economic burden of schizophrenia of €1250 million per year in direct costs, of which 20% is related to hospitalizations and pharmaceutical expenditure. With regard to social security benefits, an average annual expenditure of €160.1 million was calculated (average cost per patient = €10,675).

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

Saving more than R$ 85 billion of the Brazilian Social Security System: the case of the PRBI / Economía de más de R$ 85 mil millones en el Régimen General de Previsión Social de Brasil: el caso del PRBI / Economizando mais de R$ 85 bilhões ao Regime Geral de Previdência Social do Brasil: o caso do PRBI

Abstract Since 2016, the number of recipients of incapacity allowance in Brazil has been continuously falling. This article presents the program of incapacity benefits assessment (PRBI) to help understand the dynamics around incapacity allowance and similar benefits. The study shows that the PRBI can save more than R$ 85 billion of the budget allocated to social security in the country.

Resumen El número de beneficiarios de subsidios por incapacidad laboral ha disminuido drásticamente desde 2016. Este artículo muestra que el Programa para la Evaluación de Subsidios por Incapacidad Laboral (PRBI) es clave para entender esta dinámica y es responsable de una economía de más de R$ 85 mil millones para el Régimen General de Previsión Social de Brasil.

Resumo O número de benefícios de auxílio-doença vem caindo drasticamente desde 2016. Este artigo mostra que o Programa de Revisão dos Benefícios por Incapacidade (PRBI) é fundamental para entender essa dinâmica, e estima que o Programa seja responsável por uma economia de mais de R$ 85 bilhões ao Regime Geral de Previdência Social.

Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV.

BACKGROUND: Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries' bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress. METHODS: PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized ("choice") study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators. DISCUSSION: The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103) .

Medical labour under neoliberalism: an ethnographic study in Colombia.

OBJECTIVES: In order to increase the knowledge about the impacts of neoliberal market forces on physician's labour, this article's objectives are to analyse how and why the labour of physicians is transformed by neoliberalism, and the implications of these transformations for patient care. METHODS: Ethnographic investigation is carried out through semi-structured interviews with 20 general practitioners at public and private facilities in Colombia. The interviews were contrasted with national studies of physician's labour since the 1960s. A "mock" job search was also simulated. The analysis was guided by Marxian frameworks. The study was approved by a Human Research Ethics Committee, and informed consent was obtained from all participants. RESULTS: The overpowering for-profit administration of the Colombian healthcare system imposes productivity mechanisms on physicians as a result of a deregulated labour market characterized by low salaries, reduced and self-funded social security benefits, and job insecurity. Overworked physicians with reduced autonomy become frustrated for not being able to provide the care their patients need according to clinical standards. CONCLUSIONS: Under neoliberal conditions, medical labour becomes exploitable and directly productive through its formal and real subsumption to Capital. The negative consequences of a progressive loss in physician's autonomy unveil the incompatibility between neoliberal health systems and people's health.

Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries.

The COVID-19 pandemic is a reminder that insufficient income security in periods of ill health leads to economic hardship for individuals and hampers disease control efforts as people struggle to stay home when sick or advised to observe quarantine. Evidence on income security during periods of ill health is growing but has not previously been reviewed as a full body of work concerning low-income and middle-income countries (LMICs). We performed a scoping review to map the range, features, coverage, protective effects and equity of policies that aim to provide income security for adults whose ill health prevents them from participating in gainful work. A total of 134 studies were included, providing data from 95% of LMICs. However, data across the majority of these countries were severely limited. Collectively the included studies demonstrate that coverage of contributory income-security schemes is low, especially for informal and low-income workers. Meanwhile, non-contributory schemes targeting low-income groups are often not explicitly designed to provide income support in periods of ill health, they can be difficult to access and rarely provide sufficient income support to cover the needs of eligible recipients. While identifying an urgent need for more research on illness-related income security in LMICs, this review concludes that scaling up and diversifying the range of income security interventions is crucial for improving coverage and equity. To achieve these outcomes, illness-related income protection must receive greater recognition in health policy and health financing circles, expanding our understanding of financial hardship beyond direct medical costs.

Investigating the relationship between changes in social security benefits and mental health: a protocol for a systematic review.

INTRODUCTION: Poor mental health is one of the greatest causes of disability in the world. Evidence increasingly shows that population mental health may be influenced by national social security policies. This systematic review aims to establish the relationship between social security and mental health in order to help inform recommendations for policy-makers, practitioners and future research. METHODS AND ANALYSIS: A systematic review of quantitative observational studies investigating mental health outcomes related to changes in social security policies will be conducted. Six major databases, including Medline, PsychInfo, Embase, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index Abstracts and Scopus, as well as Research Papers in Economics will be searched from January 1979 to April 2020. The electronic database searches will be supplemented by reference and citation searches as well as hand-searching of key journals. The outcomes of interest are objective or subjective mental health outcomes, including stress, anxiety, depression, self-reported mental health scores, subjective well-being and suicide. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the quality of the studies will be assessed by the validity assessment framework designed for appraising econometric studies. A narrative synthesis will be conducted for all included studies. If data permit, study findings will be synthesised by conducting a meta-analysis. ETHICS AND DISSEMINATION: As it will be a systematic review, without primary data collection, there will be no requirement for ethical approval. Findings will be disseminated through peer-reviewed publications and in various media, for example, conferences or symposia. PROSPERO REGISTRATION NUMBER: CRD42019154733.

Time trends and social security burden of temporary work disability due to chronic venous disease in Brazil.

BACKGROUND: Chronic venous disease (CVD) and disability are worldwide problems and have significant socioeconomic implications. This study aims to analyze the time trends and social security burden of temporary work disability due to CVD in Brazil. METHODS: An ecological time series study using the Brazilian Social Security System database was performed from 2005 to 2014. Data from all benefits granted to workers with temporary disability due to CVD were analyzed. The cases were identified using diagnosis codes I83-I83.9 of the International Classification of Diseases 10th Revision (ICD-10). The time trend analyses were performed by the Joinpoint Regression Model, with sex, age, regions, income, and category of affiliation as variables. Crude and age-standardized rates were calculated. RESULTS: A total of 429,438 benefits were granted for temporary work disability due to CVD from 2005 to 2014, with a growing trend and an age-standardized annual percent change (APC) of 3.4 (95% CI: 2.6-4.2) (p < 0.05). Social security expense increased 3.5-fold, and the number of days in benefit doubled from 2005 to 2014. In total, 27,017,818 working days were lost. The average duration of benefits was 55.3 days. The majority of workers were women (68.2%) (p < 0.001), between 30 and 59 years old, employed, had a monthly income ≤2 minimum wages (MW) (83.2%), and lived in the regions southeast (53.6%) and south (29.3%). Significantly higher APCs were observed for women than for men (APC: 4.9, 95% CI: 4.0-5.7 versus APC: 1.2, 95% CI: 0.1-2.4). All regions in Brazil had a significant growing trend, except in the north. No significant growth was observed in the age group of 60-69 years. A decreasing trend was observed in workers with monthly incomes above 2 MW (p < 0.05). CONCLUSIONS: Temporary work disability due to CVD and social security burden showed increasing trends with millions of working days lost, particularly among women and low-income workers. Preventing disability is challenging, and public policies are needed to reduce the social and economic impact of disability. Therefore, measures for promoting health at the workplace should be encouraged.

The economic burden of dissociative disorders: A qualitative systematic review of empirical studies.

OBJECTIVE: Dissociative disorders (DDs) are associated with intensive, long-term treatment, suicidality, recurrent hospitalizations, and high rates of disability. However, little is known about the specifics of the economic burden associated with DDs. This worldwide, systematic review examines the results of studies in adults on direct and indirect costs associated with DDs. METHOD: We searched 6 databases and the reference lists of articles. We also approached researchers to identify unpublished studies. No language restrictions were imposed. RESULTS: A total of 1,002 records met the search criteria, of which 29 papers were selected for full-text inspection. Ultimately, of these, we reviewed four empirical studies. We provide a narrative discussion of study findings. Our findings suggest that DDs are costly to society, and that there is a reduction in service utilization and associated costs over time with diagnosing of and specialized treatment for DDs. However, the overall quality of the economic evaluations was low; several types of DDs, comorbid conditions, and costs were not included; and men were underrepresented. Due to the heterogeneity among studies, we could not perform a meta-analysis. CONCLUSIONS: Due to the heterogeneity and low quality of the identified economic evaluations, no firm conclusions about the economic burden of DDs alone can be drawn. Higher quality research, including a detailed description of the study design, population, and primary outcome measures used, utilizing appropriate clinical alternatives and including major comorbidities, is urgently needed to more rigorously assess the economic impact of DDs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A three-stage DEA-based efficiency evaluation of social security expenditure in China.

There is an increasingly growth of China's social security expenditure(SSE) during the past decade. Regarding to the great responsibility and impact on citizens' welfare and economic development, the efficiency of social security expenditure has inevitably become the focus of growing attention. Based on Chinese provincial panel data over the period 2007-2016, a three-stage DEA model was conducted and found that the efficiency level of 29 provinces/municipalities did not reach the efficiency frontier. Environmental factors and statistical noises have a significant impact on the efficiency of SSE, if environmental factors and statistical noises are not considered, the efficiency of SSE in China is likely to be underestimated. The regional differences in the efficiency of SSE were significant and ranked by descending order as follows: central region, eastern region and western region.

Cognitive Impairment and Social Security's Representative Payee Program.

Social Security's Representative Payee Program faces a difficult balance with respect to dementia: Many people living with dementia can conduct their finances without a payee if they have help from informal caregivers, but those without help are at risk. To date, it has been unclear what share of retirees with dementia use a payee, what share has help potentially available from another source, and what share has no observed means of assistance. This study finds that while fewer than 10% of retirees with dementia use a payee, only about 8% have no observed means of help.

Impacto do afastamento do trabalho por doenças inflamatórias intestinais no Brasil / Impact of work disability due to inflammatory bowel diseases in Brazil

As doenças inflamatórias intestinais (DII) podem ter impactos sociais e econômicos no Brasil, onde sua prevalência aumentou recentemente. Este estudo tem como objetivo principal avaliar a incapacidade por DII na população brasileira, descrevendo proporções com fatores demográficos e como objetivo secundário, a avaliação de possíveis fatores de risco de afastamento do trabalho por Doença de Crohn (DC) em um centro de referência em DII da Universidade do Estado do Rio de Janeiro (UERJ), cujo resultado pode refletir outras regiões do país. A análise foi realizada utilizando-se a plataforma do Sistema Único de Informações sobre Benefícios da Previdência Social, com um primeiro cruzamento de dados de auxílios doença e aposentadorias por invalidez com DC e Retocolite Ulcerativa (RCU) entre 2010-2014. Dados adicionais como valores médios de benefícios, duração do benefício, idade, sexo e região foram obtidos através da mesma plataforma. Um segundo cruzamento entre auxílios doença e aposentadorias por invalidez foi feito somente para DC entre 2010-2018 no estado do Rio de Janeiro e foram pesquisados os mesmos dados adicionais. Uma subanálise foi realizada nos casos de incapacidade em comum com os pacientes com DC da UERJ, para avaliação das características que teriam maior chance de atuar como fator de risco para afastamento do trabalho, se comparando com a população de DC desse ambulatório que não teve afastamento pelo Instituto Nacional do Seguro Social (INSS). No Brasil, a incapacidade temporária ocorreu com maior frequência na RCU enquanto a permanente na DC. A DC afastou pacientes mais jovens que a RCU e ambas mais mulheres que homens. As ausências temporárias do trabalho por DC e RCU foram maiores no Sul e as menores ausências por DC foram observadas no Norte e Nordeste. A média de dias de incapacidade foi longa, de quase um ano, sendo maiores na DC em comparação à RCU, porém ambos tenderam a diminuir de 2010 à 2014. O valor dos benefícios pagos pelas DII representou aproximadamente 1% de todos os benefícios da mesma natureza no país, sendo 51% dos gastos com DC. No RJ, a prevalência da DC foi de 26 por 100.000/habitantes, com custo indireto de 0,8% dos benefícios totais, apresentando taxa de 16,6% de incapacidade, similar a encontrada no grupo de pacientes da UERJ. Os fatores de risco de incapacidade por DC na UERJ foram idade menor que 40 anos a época do diagnóstico, tempo de duração da doença, cirurgia intestinal prévia e fístula anovaginal. Dos afastados, 19% apresentaram depressão ou ansiedade associados. A média de tempo entre o diagnóstico de DC e a incapacidade foi de 3 anos. No Brasil, as DII frequentemente causam incapacidade prolongada e podem gerar aposentadorias precoces, com programas de reabilitação profissional ainda pouco explorados. As tendências de redução das taxas de incapacidade no Brasil podem refletir melhorias no acesso a cuidados de saúde e a medicamentos. Os custos indiretos baseados apenas no absenteísmo em empregos foram significativos e a demonstração desse impacto socioeconômico e de fatores de risco de incapacidade podem auxiliar no planejamento de políticas públicas para o país.

Inflammatory bowel diseases (IBD) can lead to Brazil's social and economic impacts, where their prevalence has recently increased. This study's main objective is to evaluate the disability due to IBD in the Brazilian population describing proportions with demographic factors. Secondly, it assesses possible risk factors of absence from work due to Crohn's disease (CD) in a referral center of IBD of the State University of RJ (UERJ), which results may reflect other regions of the country. The analysis was performed using the Unified Social Security Benefits Information System platform, with the first crossing of data on sickness benefits and disability pensions with CD and Ulcerative Colitis (UC) between 2010- 2014. Additional data, such as average benefit values, benefit duration, age, sex, and region of the country, were obtained through the same platform. A second crossing between sickness benefits and disability pensions was made only for CD between 2010-2018 in the state of Rio de Janeiro (RJ) for the evaluation of the same additional data. A subanalysis was made in cases of CD disability in common with patients at UERJ, to assess the characteristics that would have a greater chance as a risk factor for absence from work, compared to the population of CD of this clinic that had no disability by the Institute National Social Security (INSS). In Brazil, temporary disability occurred more frequently in the UC while the permanent one in CD. Disability occurred in patients with CD younger than UC and both more in women than in men. Temporary absences from work due to CD and UC were more significant in the South, and the lowest absences due to CD were observed in the North and Northeast. The average number of days of disability was long, almost one year, being higher in CD than in UC, but both tended to decrease from 2010 to 2014. IBD's benefits represented approximately 1% of all the benefits of sickness in the country, with 51% of DC spending. In RJ, the prevalence of CD was 26 per 100,000 / inhabitants, with an indirect cost of 0.8% of total benefits, with a rate of 16.6% of disability, similar to that found in the group of patients at UERJ. The risk factors for CD disability in UERJ were age under 40 at the time of diagnosis, duration of the disease, previous intestinal surgery, and anovaginal fistula. Of those on absence from work 19% had associated depression or anxiety. The average time between the diagnosis of CD and disability was three years. In Brazil, IBDs often cause prolonged disability and can lead to early retirements, with professional rehabilitation programs still little explored. Trends in the reduction of disability rates in Brazil may reflect improvements in access to healthcare and medicines. The indirect costs with IBD in Brazil, based only in absenteeism, were significant, and demonstrating this socioeconomic impact and risk factors for disability can help plan public policies for the country.

Erosão orçamentário-financeira dos direitos sociais na Constituição de 1988 / Budgetary-financial erosion of social rights in the Constitution of 1988

Resumo Ao longo das três décadas de vigência da Constituição Federal, redesenhos normativos e fiscais foram introduzidos pela União nas garantias de organização federativa solidária e de custeio dos direitos sociais, a pretexto de resguardar a sustentabilidade intertemporal da dívida pública brasileira. Para equalizar a tensão entre estabilidade econômica e efetividade dos direitos sociais e sua repercussão para o processo de endividamento, foram mitigados paulatinamente os pisos de custeio da saúde e educação e o orçamento da seguridade social, os quais operavam, tanto no campo simbólico, quanto no pragmático, como uma espécie de contrapeso fiscal à necessidade de custo alegadamente ilimitado para as políticas monetária e cambial. Desvincular receitas, reduzir o escopo dos regimes de gasto mínimo e restringir o alcance interpretativo de transferências intergovernamentais equalizadoras das distorções federativas tornou-se estratégia, assumida - direta ou indiretamente - pela União desde o início da década de 1990, de estabilização macroeconômica, sobretudo, monetária. Assim tem sido empreendido um longo e ainda atual processo de desconstrução orçamentário-financeira dos direitos sociais, que restringe a identidade estrutural da CF/1988, a pretexto de consolidação fiscal cada vez mais exigente da redução do tamanho do Estado.

Abstract Throughout the three decades of the Federal Constitution, normative and fiscal redesigns were introduced by the Union in the guarantees of solidary federative organization and of social rights costing, under the pretext of safeguarding the intertemporal sustainability of the Brazilian public debt. In order to equalize the tension between economic stability and the effectiveness of social rights and their repercussion for the indebtedness process, the health and education minimum spending and the social security budget were gradually mitigated, which operated both in the symbolic field and in the pragmatic, as a kind of fiscal balance to the need for allegedly unlimited cost for monetary and cambial policies. Unlink taxes, reduce the scope of minimum spending regimes and restrict the interpretative scope of intergovernmental equalization transfers of federative distortions has become a strategy, assumed - directly or indirectly - by the Union since the early 1990s, of macroeconomic stabilization policy, above all, monetary. Thus, a long and still ongoing process of budgetary and financial deconstruction of social rights has been undertaken, which restricts the structural identity of the FC/1988, under the pretext of increasingly demanding fiscal consolidation of the reduction of the size of the state.

Costes sanitarios de las enfermedades profesionales: análisis de una serie de pacientes de un hospital público / Health care costs of occupational disease: analysis of a patient series at a public hospital

El infra-reconocimiento secular de las enfermedades profesionales (EP) en España provoca un intercambio de pacientes y recursos entre el Sistema Nacional de Salud y el de Seguridad Social. Se estimaron los costes asistenciales directos de una serie de pacientes de un hospital de Barcelona diagnosticados de EP por su Unidad de Patología Laboral. La información sobre todas las asistencias asociadas al diagnóstico de EP fue revisada sistemáticamente. El valor económico de cada asistencia se obtuvo de la contabilidad de costes y sistema de facturación del hospital. En total, se computaron 524 asistencias de 33 pacientes, con un coste medio de 345,5 €, siendo el más alto para las hospitalizaciones (4.032,5 €). El coste medio por paciente fue de 5 €. Estos resultados ponen de manifiesto la necesidad de coordinación entre el Sistema Nacional de Salud y el de Seguridad Social para un adecuado reconocimiento de EP

The consistent under-recognition of occupational diseases (OD) in Spain leads to an exchange of patients and resources between the country's National Health System and the Social Security System. We examined the direct healthcare costs of a series of patients diagnosed with OD by the Clinical Occupational Diseases Unit in a Barcelona hospital. Information on all care associated with the diagnosis of PD was systematically reviewed. The economic value of each episode of care was obtained from the hospital cost accounting and billing system. Overall, we computed costs for 524 episodes in 33 patients. The average cost was 345.5 €, being highest for hospital admissions (4,032.5 €). The average cost per patient was 5,486.2 €), and for cancer 15,223.3 €. These results highlight the need for coordination between the National Health System and the Social Security System so that OD can be appropriately recognized

Budgetary-financial erosion of social rights in the Constitution of 1988. / Erosão orçamentário-financeira dos direitos sociais na Constituição de 1988.

Throughout the three decades of the Federal Constitution, normative and fiscal redesigns were introduced by the Union in the guarantees of solidary federative organization and of social rights costing, under the pretext of safeguarding the intertemporal sustainability of the Brazilian public debt. In order to equalize the tension between economic stability and the effectiveness of social rights and their repercussion for the indebtedness process, the health and education minimum spending and the social security budget were gradually mitigated, which operated both in the symbolic field and in the pragmatic, as a kind of fiscal balance to the need for allegedly unlimited cost for monetary and cambial policies. Unlink taxes, reduce the scope of minimum spending regimes and restrict the interpretative scope of intergovernmental equalization transfers of federative distortions has become a strategy, assumed - directly or indirectly - by the Union since the early 1990s, of macroeconomic stabilization policy, above all, monetary. Thus, a long and still ongoing process of budgetary and financial deconstruction of social rights has been undertaken, which restricts the structural identity of the FC/1988, under the pretext of increasingly demanding fiscal consolidation of the reduction of the size of the state.

Ao longo das três décadas de vigência da Constituição Federal, redesenhos normativos e fiscais foram introduzidos pela União nas garantias de organização federativa solidária e de custeio dos direitos sociais, a pretexto de resguardar a sustentabilidade intertemporal da dívida pública brasileira. Para equalizar a tensão entre estabilidade econômica e efetividade dos direitos sociais e sua repercussão para o processo de endividamento, foram mitigados paulatinamente os pisos de custeio da saúde e educação e o orçamento da seguridade social, os quais operavam, tanto no campo simbólico, quanto no pragmático, como uma espécie de contrapeso fiscal à necessidade de custo alegadamente ilimitado para as políticas monetária e cambial. Desvincular receitas, reduzir o escopo dos regimes de gasto mínimo e restringir o alcance interpretativo de transferências intergovernamentais equalizadoras das distorções federativas tornou-se estratégia, assumida ­ direta ou indiretamente ­ pela União desde o início da década de 1990, de estabilização macroeconômica, sobretudo, monetária. Assim tem sido empreendido um longo e ainda atual processo de desconstrução orçamentário-financeira dos direitos sociais, que restringe a identidade estrutural da CF/1988, a pretexto de consolidação fiscal cada vez mais exigente da redução do tamanho do Estado.

Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance.

BACKGROUND: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? METHOD: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. RESULTS: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. CONCLUSIONS: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure.