O estudo Judicialização dos planos e seguros de saúde coletivos no Tribunal de Justiça de São Paulo trata das ações judiciais relacionadas a planos e seguros de saúde coletivos, julgadas pela segunda instância do Tribunal de Justiça de São Paulo nos anos de 2013 e 2014. São descritas e analisadas as demandas levadas ao Poder Judiciário pelos consumidores de planos de saúde. Os conflitos envolvem coberturas, reembolso, aposentados e demitidos, reajustes aplicados sobre a mensalidade, cancelamento de contrato e descredenciamento de hospitais. Também são analisados o comportamento e as argumentações da Justiça nas decisões. Conclui-se pela necessidade de aprimoramento da regulamentação e da fiscalização das atividades dos planos e seguros de saúde / The Judicialization of plan and collective health insurance study at the Court of Law of Sao Paulo treats legal actions related to plans and collective health insurances judged by the Court of Law of São Paulo of Second Instance in 2013 and 2014. It was described and analyzed the demands referred to Judiciary branch by health plan consumers. The conflicts involve coverage, reimbursement, retired and dismissed people, readjustments applied on the monthly payment, contract cancelling and hospital loss of accreditation. It is also analyzed the behavior and arguments of Justice on decisions. It is evidenced the need of improving the regulation and supervision of health plans and insurances

O presente trabalho aborda o problema da variabilidade da prática médica, entendida como as variações sistemáticas na utilização de um procedimento médico ou cirúrgico após terem sido descartadas como causas as diferenças entre as populações e os pacientes. Teoricamente se espera que o comportamento dos médicos seja uniforme, isto é, que frente a uma população fixa, a taxa de encaminhamento dos médicos a procedimentos diagnósticos ou tratamentos hospitalares seja muito parecida, mas na realidade a taxa de encaminhamento segue uma distribuição que da conta dá variabilidade na prática médica. A partir do banco de dados de uma seguradora de saúde colombiana, foi realizada uma vasta análise estatística que permitiu encontrar variáveis importantes para a abordagem do problema. Dentre as variáveis estudadas, mereceram destaque a distribuição de pacientes atendidos pelos médicos (concentração) e a taxa de encaminhamento para cirurgia. O trabalho procura, a partir de simulação computacional, utilizando modelagem baseada em agentes, reproduzir as funções de distribuição empíricas referentes a concentração e a taxa de encaminhamento para procedimentos cirúrgicos. O modelo está baseado na hipótese econômica da renda alvo, teoria da sociologia dos grupos e em dados empíricos. / This study addresses the problem of medical practice variation (MPV), which is the presence of variation in the use of a medical procedure that is not explained by environmental, demographic or epidemiological differences. Theoretically, it is expected that the behavior of physicians were uniform for a fixed population, the rate of remission for diagnostic procedures or hospital treatment must be very similar, but in practice the remission rate follows a distribution that account the variability in medical practice. We used the data base of a Colombian health insurance company. Statistical analysis found important variables to approach the problem as: distribution of patients seen by the physician (concentration) and the rate of referral for surgery.

Made available in DSpace on 2016-03-15T19:34:13Z (GMT). No. of bitstreams: 1 Kristian Rodrigo Pscheidt.pdf: 1499656 bytes, checksum: 3cc5c8a5b3bd4a2d699218665afbbaef (MD5) Previous issue date: 2014-02-18 / Notwithstanding the State holds the obligation to provide an universal, free and full health service for the citizens, the actual regulatory act 9.656/1998 enforced by a structural analysis, emphasizes that the health service has been delegated to private, embodied in the health insurance, which currently has 48.7 million beneficiaries and has unique characteristics. Thus, the analysis of the segment needs to be viewed, first from the constitutional formalisms, and after by the relationship view the government policy. The establishment of a regulatory agency and the policies adopted by the Agência Nacional de Saúde Suplementar (ANS) reveals that the goal of the State is vent the public health system (SUS) by transfer primary obligations to healthcare operators. The beneficiaries of health insurance plans through regulatory provisions, went on to become privately funded initiative. It happens that the replacement of the State to private without considering the peculiarities of the sector has resulted in the depletion of the financial ability of health insurance companies, indicating that the mode of regulation designed for the segment may not be consistent with the optimization of this scarce resource. / Não obstante o Estado deter o dever de prestar assistência universal, gratuita e integral à saúde do cidadão, o marco regulatório da saúde suplementar, consubstanciado pela Lei 9.656/1998, pautado por uma análise histórico-estrutural, permite concluir pela transferência de parte desta responsabilidade à iniciativa privada, em especial as operadoras de planos de saúde, que hoje possuem 48,7 milhões de beneficiários e detêm características ímpares. Desta forma que a avaliação do segmento deve pautar-se, a partir de sua ótica constitucional, pela relação estrutural existente entre operadoras de saúde e as políticas governamentais. Neste caminho, perceber-se que a constituição de uma agência reguladora e a forma de atuação da Agência Nacional de Saúde Suplementar (ANS) desvendam que o objetivo do Estado é desafogar o Sistema Único de Saúde (SUS) mediante a transferência de obrigações primárias às operadoras de saúde. Os beneficiários dos planos de saúde, mediante disposições regulatórias, passaram a se tornar suportados pela iniciativa privada. Ocorre que a substituição do Estado pela saúde suplementar sem considerar as peculiaridades do setor vem resultando no esgotamento da idoneidade financeira das operadoras de saúde, o que indica que o modo de regulação delineado para o segmento pode não estar em consonância com a otimização deste recurso escasso.

A presente dissertação analisa como a ausência de incentivos adequados no seguro saúde ocasiona o surgimento do fenômeno conhecido como risco moral e suas conseqüências na determinação da demanda de serviços médicos. O trabalho envolve a revisão da literatura e a estimação de um modelo econométrico que avalia a efetividade dos mecanismos de regulação no controle do risco moral por parte do paciente. A principal conclusão é que o risco moral por parte do paciente é importante para os serviços ambulatoriais, mas não ocorre nos serviços hospitalares. / This dissertation analyses how the lack of appropriate incentives motivates the emergence of moral hazard in health insurance and its consequences in the determination of medical services demand. The involves the literature review and the estimation of a econometric model, which evaluates the effectiveness of rationing mechanisms in the control of moral hazard motivated by the patient. The main conclusion is that moral hazard motivated by the patient is significant for ambulatory care, but it does not occur for inpatient care.

La couverture universelle de santé est aujourd’hui au coeur du financement de la santé. Dans ce contexte, le développement des mécanismes d’assurance et l’amélioration de l’efficience constituent des enjeux majeurs pour garantir l’équité dans l’accès et le financement des services de santé. La transition vers la couverture universelle de santé s’appuie sur la combinaison des fonds d’équité de santé et de l’assurance santé communautaire au Cambodge et sur le développement de l’assurance santé communautaire en Chine avec le Nouveau Système de Coopératives Médicales Rurales. Alors que les modalités du financement de la santé changent, l’utilisation des ressources devient un enjeu central et on doit alors s’interroger sur leur efficience dans le contexte de la couverture universelle de santé. C’est l’objet de cette thèse qui s’articule autour de quatre chapitres. Le chapitre I analyse les enjeux du financement de la santé dans les pays en développement dans le contexte de la couverture universelle de santé, montrant pourquoi la problématique de l’efficience en constitue l’une des interrogations centrales. La thèse se concentre alors sur l’étude de l’efficience des établissements de santé au travers de trois chapitres. Le chapitre II porte sur la mesure de l’efficience technique via l’analyse d’enveloppement des données. Les chapitres III et IV présentent des études de cas portant respectivement sur l’activité et l’efficience des centres de santé de la province de Takéo au Cambodge et des hôpitaux municipaux de la préfecture de Weifang en Chine dans le contexte des réformes orientées vers la couverture universelle de santé. / Universal health coverage is at the heart of health financing. In such context, the development of insurance mechanisms and the improvement of efficiency are major stakes to insure equity in access and financing of health care services. In Cambodia, the transition to universal health coverage relies on a combination of health equity funds and community-based health insurance while in China it relies on the development of community-based health insurance with the New Rural Cooperative Medical Scheme. The composition of health financing evolves and thus, the utilization of resources becomes a central issue. So, as it proposed in this thesis, we have to examine the efficiency in the context of universal health coverage. The chapter I analyses the issues of health financing in developing countries in the context of universal health coverage and underlines why the efficiency is the central issue. The thesis then concentrates on the study of efficiency through three chapters. Chapter II details the data envelopment analysis to estimate technical efficiency. Chapters III and IV respectively study the activity and efficiency of health centers of Takeo province in Cambodia and townships hospitals of Weifang prefecture in China, in the context of reforms oriented to universal health coverage.

全民健康保險自實施以來，透過危險分擔與社會互助的原則，降低了民眾就醫時的財務障礙，進而促進了全體國民的健康。可是由於收入成長減緩與支出不斷增加的情形，使得這個制度目前已面臨嚴重的財務危機，然而在目前政治與經濟環境的雙重影響之下，健保收入已無法有效增加，因此努力控制醫療費用支出，便成為當務之急。但是全民健康保險是一項社會福利政策，不能因為控制醫療費用而降低了醫療品質。如何將醫療資源有效分配，以便減少醫療資源浪費、維持醫療品質並減輕醫療費用的支出，便需依賴一個良好的審查制度。 然而對於醫療費用的審查，不管在設計、分析、控管乃至評估上，都是知識密集的工作，而且審查的過程還必須藉由專業審查者的參與始能完成，因此如何善用資訊科技予以適當之輔助，便成為醫務管理上一個非常重要的議題。 本研究使用健保局北區分局感冒等疾病之就醫資料作為樣本，在分析過國內外對醫療費用審查的建議方式後，嘗試設計一個新的自動化審查機制，並發展一套以資料發掘為基礎的自動化審查雛型系統，希望能在醫療院所申報的記錄中找出共同的規則，並利用這些規則自動將有問題的資料篩選出來，幫助健保局與專業審查者將焦點集中在有問題的資料上，以便能更有效率的進行審查的工作。 本研究所得到的結果，經健保局人員與專業審查醫師檢視後，認為確實可行，除了證明資料發掘技術可以有效地應用在醫療費用審查，並帶來可觀的效益之外，還達到有效降低審查人力、提昇審查效率的目的。而對於這種自動篩選出異常的審查方式，應如何實際加以應用，本研究也提出了具體的建議架構及實施步驟，供健保局在未來建立自動化審查制度時的參考依據。

全民健保已於民國83年3月1日起正式開辦，其為社會保險的一種，和以往公、勞保等的社會保險，最大的不同處有二：一是將全民皆納入保險的體系中。以往的社會保險只針對特定群體承保，如公務員的公保、勞工的勞保。二是採行部分負擔制度。以往的社會保險除了掛號費外，被保險人幾乎不用再繳交其他的費用。因此，本篇論文即針對這兩個主要的不同處，做一番理論性的探討與實證上的研究。 　　在理論探討方面，是說明政府為何要介入全民健保，其與道德危險的關係如何。所採用的模型為Rothchild與Stiglitz在1976年所提出之競爭性市場下保險配置的模型，並由代表性個人擴充到兩類高低風險不同的被保險人。在實證研究方面，所利用的數據，主要是來自公、勞保的醫療費用支出的數據，再輔以必要的資料，如人口總數，各年齡層的人口分佈及醫療費用的比例，而資料為最近十年間的數據。其方法為先利用公、勞保醫療費用支出的金額，計算出平均一個人可能的醫療費用支出，再透過各年齡層對醫療資源需求不同的程度與人口數，估算出可能的總醫療費用支出，然後再利用先前估算出的數字，求出政府方面所可能節省的醫療費用支出，以及社會福利損失所可能減少的金額。 　　本論文的結論認為，全民健保中的部分負擔制度，確實能發揮抑制道德危險的效果，不論是在政府的醫療費用支出方面，或是整個社會支出的變動方面，都可以看得出有不錯的改善情形。但在長期趨勢預估方面，值得注意的是，醫療費用支出的成長會大於保費收入的增加，若不提早因應與改善規劃，全民健保也有可能會出現入不敷出的情形。因此，全民健保仍有努力與改善的必要。

由於我國在社會、經濟、政治方面快速發展，人民普遍要求實施全民健康保險。在長達七年的規劃之下，終於在八十三年七月實施。全民健康保險法可說是我國有史以來最重要的民生法案，其不僅具有具體的福利效益和保障國民免於疾病的威脅的功能，而且更具有已邁向福利社會的具體意義。 　　隨著各國民主政治的發展，人民參與政治過程的機會和方式愈來愈多，我國全民健康保險法草案合法化過程中由於爭議極多，例如保險費負擔比例、保險機構的體制、分級轉診的部分負擔等，各個利益團體也不斷介入其中，使得全民健康保險法草案合法化過程更為熱鬧非凡，同時，也充滿了政治性和妥協性。 　　全民健康保險制度的實施，其成敗關鍵在於現制缺失的徹底消除，醫療體系的健全與效率，以及全體國民的共識與維護。任何制度的實施都會有一段陣痛期，唯有多方面加以配合，才能使全民健康保險成為可長可久的制度。

<p><strong>Essay in Political Science, C-level, by Camila Alvarez Cea, spring semester 2010.</strong></p><p><strong> </strong></p><p><strong>Tutor: Alf Sundin</strong></p><p><strong>“Reality or a Political Mirage? – A Study of the Swedish Press Views on the Health Insurance Reform in the USA”</strong></p><p> </p><p>The purpose of this essay is partly to examine whether the picture that Swedish press presents of the health insurance reform in the US, which is part of the Patient Protection and Affordable Act bill, will be of crucial importance to the possibilities that the American population has to receive health insurance. The main research question is accordingly: <em>“Does the picture that Swedish press presents of the health insurance reform in the USA, seem like something that will be of radical importance to the possibilities of the population to receive healthcare?”</em> The purpose is also to examine in which model (demand or market) the opinions of the Swedish press fits. This purpose will be answered by using three specific questions asking whether their opinions differ when it comes to three criterions: organization, financing/resources and delivery systems. These criterions come from a model from Milton I. Roemer’s book “National health systems of the world,” which also is the theoretical foundation of this essay.</p><p> </p><p>The methodological approach of this essay is a qualitative text analysis along with an analysis chart, where the three criterions have been examined from the reporting of the four Swedish newspapers chosen for this essay. The conclusions that have been reached from the analysis chart are that the opinions differ greatly within Swedish press, and that the picture that Swedish press presents of the health insurance reform is that it will become easier for the American population to receive health care.</p>

At the turn of the year 2009/2010 there was a change in the regulations on sickness impact. This led to 328 persons in County of Kronoberg had an expired period of sickness benefit from the Social Insurance Office (Försäkringskassan) when they reached the maximum time for sickness or temporary disability compensation. These individuals were offered introductory programs with the employment services. The purpose of this study is to investigate how the population with expired period of sickness benefit from the Regional Social Insurance Office in the County of Kronoberg (Försäkringskassan Kronoberg) is described in the initial stage, and to explore how individuals who achieved expired period of sickness benefit from the Social Insurance Office (Försäkringskassan) talks about the meaning to get an expired period of sickness benefit regarding economic and social issues. The study was inspired by Grounded theory. The method has consisted of both quantitative and qualitative interviews. In total, six persons participated in the surveys. Narrative method was used in the interview with a person with experience of an expired period of sickness benefit from the Social Insurance Office (Försäkringskassan). The interviews indicate that the authorities have different focus on the concept of rehabilitation. This means that what is to be regarded as rehabilitation and the efforts which may benefit the individual depends on which authority has the power of definition. This study is made before preparing administrators for either statistics or working methods were established by the relevant authorities. Longer experience in the field is still missing about what the change means for both individuals who have experience of the expired period of sickness benefit and professionals. This points out; further research in this area is needed.