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Made available in DSpace on 2016-04-26T20:21:01Z (GMT). No. of bitstreams: 1 Juliana Labaki Pupo.pdf: 1195491 bytes, checksum: b2cbd08658c890e4e9a484f36d27959b (MD5) Previous issue date: 2012-06-04 / The present dissertation will present an overview about private health assistance in Brazil, having as its central theme the responsibility of Health Insurance Companies and credentialed Hospitals. It will be demonstrated the constitutional view, with the approach of the dignity principle of the human being, the main pillar of the right to health. The ways of health assistance provided by State will be discussed focusing on the activity rendered by private companies. The analysis of the context of Civil responsibility will be deepened, making a parallel between the subjective and objective responsibility, as well as a brief study on the transformation of the law in the post-modern society. Furthermore, it shall be detailed the legal nature of health insurance contracts and the applicability of the Consumer Defense Code , in which the objective responsibility by the risk of the supplier activity will prevail. The hospital activity and the extension of the health insurance companies responsibility for such services will also be discussed, considering that the hospital is chosen by the company, thus making a tripartite among ``Health Insurance Company-Hospital-Beneficiary´´. It shall be observed the sympathy among the suppliers, by demonstrating that the patient is supported by the laws of consumers protection and defense, aiming to guarantee full and effective assistance to their health / O presente estudo traça um panorama sobre a assistência privada à saúde no Brasil, tendo como tema central a responsabilidade das operadoras e dos hospitais credenciados. Será demonstrada a visão constitucional, com a abordagem do princípio da dignidade da pessoa humana, alicerce do direito à saúde. Serão mencionadas as formas de prestação de assistência à saúde pelo Estado, focando na atividade prestada pela iniciativa privada, por meio das operadoras. A análise do contexto da responsabilidade civil será aprofundada, traçando paralelo entre a responsabilidade subjetiva e objetiva, assim como um breve estudo sobre a transformação do Direito na sociedade pós-moderna. Em seguida, serão detalhadas a natureza jurídica do contrato de planos de saúde e a aplicabilidade do Código de Defesa do Consumidor às suas relações, em que prevalece a responsabilidade objetiva pelo risco da atividade do fornecedor. Também serão abordadas as atividades hospitalares e a extensão da responsabilidade da operadora por tal serviço, considerando que o hospital foi por ela escolhido, formando a relação tripartite entre Operadora-Hospital-Beneficiário . Observar-se-á a solidariedade entre os fornecedores, com a demonstração de que o paciente está amparado pelas leis de proteção e defesa do consumidor, com objetivo de garantir atendimento pleno e eficaz à sua saúde

Background. In average hypertensive patients m China, approximately 3-4 major cardiovascular disease (CVD) events can be prevented in 100 treated with anti-hypertensive drugs for 5 years. Previous cross-sectional studies in healthy individuals showed that their willingness to payout of pocket for anti-hypertensive drugs dropped substantively after they were informed of the quantitative benefits, harms and costs of the treatment. These findings suggest, importantly, that patients should be provided with evidence and engaged in decision making for such conditions as hypertension in order to make decisions that will satisfy patients. This large effect of evidence-informed decision making found in the cross-sectional study has, however, not been confirmed in more rigorous studies and in diagnosed hypertensive patients in the country. We therefore conducted this randomized controlled trial to assess the effect of individualized, evidence-based counseling on medicine-using behaviors of hypertensive patients. / Methods. This is a randomized controlled trial with 210 patients with mild hypertension and free of CVD recruited in two primary care centers in Shenzhen, China. Individualized, evidence-based counseling on antihypertensive treatment and general counseling on lifestyle modifications (103 patients) were compared with general counseling alone (107 patients). The counseling was provided face-to-face and reinforced by a telephone call a week later. The key information provided in the intervention group included the lO-year CVD risk estimated based on an individual's risk factors, individualized benefit expressed in the absolute risk reduction, side effects, and costs of antihypertensive drugs. Medication use and good adherence at 6-month follow up were used as the primary outcomes. / Results. At baseline, the mean age of patients was 54.3 (SD=7.8) years, 49% were men, 62.4% were currently taking antihypertensive medicines which was all covered by health insurance. The overall attrition rate was 8.6%. At six months, the rate of medication use was marginally higher in the intervention group than that in the control group (65.0% vs 57.9%; odds ratio (OR) = l.35, 95% confidence interval (Cl): [0.77, 2.36]; P value= 0.290). The rate of good adherence in the intervention group was also slightly higher than that in the control group (43.7% vs 40.2%; OR= 1.15, 95% Cl: [0.67, 2.00]; P value= 0.607). The difference in medication use and good adherence between the intervention and control groups was however not statistically significant. The results remained unchanged in multivariate and sensitivity analyses. / Conclusions. The individualized, evidence-based counseling made little difference to the use of and adherence to anti-hypertensive medications in insured patients with mild hypertension in China. The lack of effect of informed decision making is likely a result of persistence of entrenched practice in particular for insured clinical conditions. The finding of this study raises important questions as to whether insurance policies and clinical guidelines reflect the true needs and opinions of the patients, and about the usefulness of informing and engaging patients in decision-making under such circumstances. / 背景：對100 例一般中國高血壓患者，進行持續5 年的降壓藥物治療，可預防心腦血管事件3-4 例。健康人群中進行的橫斷面調查結果顯示，研究對象在獲得降塵藥物治療量化的收益、副作用和花費的信息後，其支付意願明顯下降。此結果的重要提示是，應向患者提供此類信息，並且患者參與自身的醫療決策，使其能夠做出符合其價值觀等的決定。然而，目前尚未在中國開展相闊的隨機對照試驗。上述知情決策的顯著效果亦尚未在患者中得到證實。在此項隨機對照試驗中，我們蚣評價個體化、循證諮詢對高血壓患者服藥情況的影響。 / 方法：這是一項雙中心的隨機對照試驗。研究共納入輕度高血壓患者210例，這些患者均無心腦血管病。干預組患者(共103 例)接受關於降壓藥物的個體化、循證諮詢和生活習慣調整的一般諮詢，對照組患者(共107 例)僅接受一般諮詢。我們為每組患者均提供當面諮詢，並於一周後通過電話進行加強。為干預組患者提供的主要信息包括:基於每例患者危險因素評估的10 年心血管病風險，降塵藥物治療的收益、副作用及花費。其中收益以絕對風險降低表示。以諮詢結束後六個月時患者服藥和良好依從性作為主要結局指標。 / 結果：基線調查中，患者的平均年齡為54. 3 (標準差為7.8) 歲，有49% 的患者為男性， 62. 峭的患者目前正在服用降塵藥物，所有患者的降塵藥物花費均由醫療保險全部或部分支付。研究中總失訪率為8.6% 。諮詢結束後六個月，干預組患者整體服藥率較對照組患者稍高(干預組65.0% 對照組57.9%比值比:1.35，95%可信區問: [0.77 ，2.36];p=0.290) 。干預組患者中，良好依從性的比例亦稍高於對照組(干預組43.7%，對照組40.2%:比值比:1.15 , 95%可信區問: [0.67，2.00]; p= 0.607)。在多因素分析和敏感性分析中，上述結果均無顯著變化。 / 結論：個體化、循證諮詢並未明顯改變中國醫療保險覆蓋下輕度高血壓患者的服藥情況。知情決策無明顯效果很可能由固定化的醫療實踐導致，這種情況對醫療保險覆蓋的治療尤其突出。此研究的發現還引出了兩個重要問題:現行的醫療保險制度和臨床指南是否反映患者的真實需要和想法，患者知情並參與決策是否必要。 / Di, Mengyang. / Thesis Ph.D. Chinese University of Hong Kong 2015. / Includes bibliographical references (leaves 127-139). / Abstracts also in Chinese; some appendixes in Chinese. / Title from PDF title page (viewed on 06, October, 2016). / Di, Mengyang. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only.

本文之研究目的，即在探討我國農民健康保險制度現存之問題，並藉由文獻分析，探討目前世界各國以特別體系辦理農民經濟安全保障之情形，瞭解農民健康保險現行制度運作情形及其所面臨之問題，以評析我國農民保險制度之缺失及可行之改進方向，最後提出農民健康保險條例之修正建議，以為未來修法之參考。 經本文之探討發現，目前世界各國以特別體系辦理農民經濟安全保障者僅數少數，且其農民保障制度除了立基於保障農民生活、改善農家所得水準之出發點外，也同時肩負改善農民地位，提昇務農意願、降低農業勞動者年齡等目標。 至於目前農保所面臨之課題方面，包括行政監理體系複雜，且中央主管機關與承保機關之隸屬關係薄弱；投保資格之規範與農民健康保險之制度目的不合，而與現實脫鉤，造成農保被保險人人數與實際從事農業人數之偏離；被保險人年齡結構老化，導致保險收支平衡；保險費率偏低，造成農保鉅額赤字及財務虧損；投保金額之不合理，影響被保險人權益及農保制度之財務健全等等。 最後，本文提出農民健康保險條例之修正建議，而朝向解決現行實務上缺失，維持保險財務健全、調和權利義務一致之方向發展，以期我國社會保險制度之發展更上一層樓。 關鍵字：農民健康保險；農民健康保險條例；老年農民福利津貼；社會保險。 / In an attempt to explore the main issue of Farmers' Health Insurance system, we investigate the current welfare systems that ensure the safety of farmers' health and economic status across the whole world. Based on the literature analysis, we understand how the system implement and what the critical issues are. This helps us make some key comments on the deficiency of Taiwan's farmer health insurance system. In this regard, some improvement guidelines and suggestions are proposed for the further revision Enactment of Taiwan's Farmer Health Insurance. The major findings indicate that few countries engage in establishing the specific scheme to ensure the health and economic status of farmers. Conversely, for those countries with the above insurance scheme, they not only ensure to advance the farmer's life and income, but also regard this system as a means to raise the devotion to farming and to lower the age of the farmers. Meanwhile, the deficiencies of Farmers' Health Insurance include the complicated regulatory structure, the inadequate regulations regarding the qualifications of the insured and the aging of the insured. Besides, the insurance rate is lower than the fair rate, resulting in insufficient insurance premium such that the financial health is weakened. Finally, the contribution of this study is devoted to the social insurance system, especially focused on some suggestions that should be constructive with respect to the emendation of Enactment of Farmers' Health Insurance. Keywords : Farmers' Health Insurance, Enactment of Farmers' Health Insurance, Old-Age Farmer's Allowance, Social Insurance.

Chile has experienced great success in terms of economic growth in the last decades. This growing economy brings changes in the Chilean health care system. Its health care system was primarily funded by state sources until 1981, when a major reform was introduced that established new rules for the health insurance market. Since then, Chile has a public-private mixed health care system, both in financing and delivery of services. Citizens can choose for coverage between the Public National Health Insurance and the Private Health Insurance system. However, these systems have a common funding source coming from the mandatory contribution of employees, equivalent to 7% of their taxable income with an approximate limit of US$2,800 dollars. One of the more important Chilean health reforms towards the establishment of social guarantees was effective on July 2005, when the Regime of Explicit Health Guarantees, also known as Plan AUGE became effective. Plan AUGE is a health program that benefits all Chileans without discrimination of age, gender, economic status, health care, or place of residence. This plan includes the 69 diseases with higher impact on Chilean population in its different stages, but with feasibility of effective treatments. Changes in the health care system and its last reform brought questions about their impact on the distribution of health care services throughout country. Is Chile moving towards a better and more equitable health care system? The main purpose of this thesis is to investigate equity in health system finance and health care utilization as well as to explore alternative measurement of access to health care in Chile. The first two manuscripts examine equity issues in Chile. The purpose of the first one is to assess equity in health system finance in Chile, accounting for all finance sources. While equity in health system finance has been well studied in OECD countries, there are still few published empirical studies on Latin American health care systems, where there tends to be a wider gap in income-wealth distribution among states. This gap may increase the financial burden for people in the lower spectrum of income groups, which is the main concern in the first manuscript. It will focus on identifying policy variables that may contribute to more equitable distribution of the financial burden in health care. The equity principle we adopt for this study is the ability to pay principle. Based on this, we explore factors that contribute to inequities in the health care system finance and issues about who bears the heavier burden of out-of pocket (OOP) payment, progressivity of OOP payment, and the redistributive effect of OOP payment for health care as a source of finance in the Chilean health care system. Our analysis is based on data from the National Socioeconomic Survey (CASEN), and the 2006 National Survey on Satisfaction and OOP payments. Results from this study provide comprehensive understanding of the financial burden of health care in Chile. This study identified evidence of inequity, in spite of the progressivity of the health care system. Furthermore, our assessment of equity in health system finance identified relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. Such findings will also benefit other Latin American countries that are concerned about equity in health system finance. The purpose of the second manuscript was to assess equity in health care utilization in Chile. Secondary data analyses from the National Socioeconomic Survey (CASEN) were performed to estimate the impact of different factors including AUGE in the utilization of health care services. We used a two-part model for the analysis of frequency of health care use in the country. Four other separate two-part models were also specified to estimate the frequency of use of preventive services, general practitioner services, specialty care and emergency care. An assessment of horizontal equity was also included. Results suggest the presence of pro-rich inequities in the use of medical care. The estimation of the two-part model found key factors affecting utilization of health care services such as education and the implementation of the AUGE program. These findings provide timely evidence to policy-makers to understand the current distribution and equity of health care utilization, and to strengthen availability of health services accordingly. The third manuscript was motivated by the previous findings. Its purpose was to explore an alternative measurement for health care access. The majority of studies nowadays use a single proxy to estimate access: the use of health care services. However, we saw many limitations on this approach since it only considers people that are already using the system and ignores those that are not. The final manuscript proposed a model to estimate access to health care services based on communitarian claims. The model identified barriers to health care access as well as the preferences of the community for priority settings. / Graduation date: 2012

A globalização, a maior ou menor estabilidade financeira e política e o atual nível de desenvolvimento econômico que o Brasil vem apresentando, condição que lhe concedeu a classificação de investment grade, obtido em 30 de abril de 2008, pela Agência Standard & Poor’s, conjugado com o nível de renda que a população vem atingindo, está transformando o país num mercado atrativo ao capital externo. A regulamentação do setor de saúde privada iniciada com a lei 9656/98 e com a criação da Agência Nacional de Saúde Suplementar – ANS, em 2000, fez com que este segmento mercadológico passasse a atrair a curiosidade e, agora, o direcionamento da atenção de mega investidores. Neste mercado há uma importante participação das cooperativas médicas e odontológicas - com significativa parte no share – aproximadamente 40%, no seu conjunto. A regulamentação vem causando certa concentração do setor pela aquisição de carteiras ou até mesmo de toda a empresa, sendo que estas negociações atingem a casa dos bilhões de reais. Essas situações encontram nas sociedades cooperativas médicas e odontológicas peculiaridades que divergem destas facilidades de negociação. / Globalization, financial and political stability and current degree of economical development that Brazil are living (because of these condition Standard & Poor’s gave to Brazil the classification of investment grade on April 30th, 2008) combined with Brazilians income degree are converting Brazil in an attractive market for outside capital. Private health sector regulamentation which started with the Brazilian law number 9656 from 1998, and the creation of Agência Nacional de Saúde Suplementar – ANS (in 2000) let this sector to attract curiosity and nowadays the attention of big stakeholders. Medical and odontological cooperatives have important participation in this market with signification part in share – like 40% on its set. The regulamentation bring on a concentration in the sector by portfolio purchase or until same all firm acquisition – that involves trillion of Brazilian reais. These situations find on medical and odontological cooperatives quirks that diverge from negotiations facilities.

A globalização, a maior ou menor estabilidade financeira e política e o atual nível de desenvolvimento econômico que o Brasil vem apresentando, condição que lhe concedeu a classificação de investment grade, obtido em 30 de abril de 2008, pela Agência Standard & Poor’s, conjugado com o nível de renda que a população vem atingindo, está transformando o país num mercado atrativo ao capital externo. A regulamentação do setor de saúde privada iniciada com a lei 9656/98 e com a criação da Agência Nacional de Saúde Suplementar – ANS, em 2000, fez com que este segmento mercadológico passasse a atrair a curiosidade e, agora, o direcionamento da atenção de mega investidores. Neste mercado há uma importante participação das cooperativas médicas e odontológicas - com significativa parte no share – aproximadamente 40%, no seu conjunto. A regulamentação vem causando certa concentração do setor pela aquisição de carteiras ou até mesmo de toda a empresa, sendo que estas negociações atingem a casa dos bilhões de reais. Essas situações encontram nas sociedades cooperativas médicas e odontológicas peculiaridades que divergem destas facilidades de negociação. / Globalization, financial and political stability and current degree of economical development that Brazil are living (because of these condition Standard & Poor’s gave to Brazil the classification of investment grade on April 30th, 2008) combined with Brazilians income degree are converting Brazil in an attractive market for outside capital. Private health sector regulamentation which started with the Brazilian law number 9656 from 1998, and the creation of Agência Nacional de Saúde Suplementar – ANS (in 2000) let this sector to attract curiosity and nowadays the attention of big stakeholders. Medical and odontological cooperatives have important participation in this market with signification part in share – like 40% on its set. The regulamentation bring on a concentration in the sector by portfolio purchase or until same all firm acquisition – that involves trillion of Brazilian reais. These situations find on medical and odontological cooperatives quirks that diverge from negotiations facilities.

The area of a sickness insurance, I have chosen for my diploma thesis, is not only important for me in terms of my working life, but as well as for my private life, because a temporary working incapacity and a title for sickness insurance benefits accompanies a life of each of us, either directly in our family circle or among friends or colleagues. The working incapacity, as a social event, is familiar to all of us. Someone meets it more often, someone less often, however it always influences our private as well as working life from a financial perspective, it has an impact on our working duties and it strikes our family groove. At the same time it has a very human dimension, since it concerns the most valuable we have ? it is our health. It deepens solidarity among people, mutual support and empathy. I have chosen the above topic also for the reason that I had already been working in the area of the sickness insurance for five years. I am interested whether there have been met the main objectives from the new legislation especially in terms of savings in financial means, a decrease of a number of temporary incapacities and a prevention of a misusage of the temporary working incapacities. The main aim of this thesis is to analyze individual areas of an implementation of the sickness insurance and on the basis of obtained results and statistical data to evaluate whether the main objectives of the sickness insurance legislation from January 1st, 2009 in the region of Jindřichův Hradec were met. Three hypotheses were presented in the thesis. The first premise said that with the effectiveness of this law financial means had spent on the sickness insurance benefits had been saved. The second premise was a decrease of the temporary incapacities and the third proven one was the meeting of the main objectives of the legislation in the whole implementation range of the sickness insurance in the region of Jindřichův Hradec. Two research methods were chosen; an analysis of documents, a technique of a secondary analysis and a content analysis. The second method was a semi-structured interview with professionals in the area of the sickness insurance. Defined hypotheses were confirmed by the carried out research. Financial means spent on the sickness insurance benefits were saved very dramatically already in the first half of the effectiveness of this law and the number of temporary incapacities decreased by one third of cases in that period. The third hypothesis was also confirmed by both chosen research methods and defined objectives of the new legislation were met in the region of Jindřichův Hradec. The defined aims of the diploma thesis were achieved, hypotheses were verified, there were mentioned important remarks and changes and provisions, which would lead to another streamlining of the sickness insurance system, were proposed. The obtained results are beneficial for my work in this area and they are a motivation as well as a challenge to other research activities.

A globalização, a maior ou menor estabilidade financeira e política e o atual nível de desenvolvimento econômico que o Brasil vem apresentando, condição que lhe concedeu a classificação de investment grade, obtido em 30 de abril de 2008, pela Agência Standard & Poor’s, conjugado com o nível de renda que a população vem atingindo, está transformando o país num mercado atrativo ao capital externo. A regulamentação do setor de saúde privada iniciada com a lei 9656/98 e com a criação da Agência Nacional de Saúde Suplementar – ANS, em 2000, fez com que este segmento mercadológico passasse a atrair a curiosidade e, agora, o direcionamento da atenção de mega investidores. Neste mercado há uma importante participação das cooperativas médicas e odontológicas - com significativa parte no share – aproximadamente 40%, no seu conjunto. A regulamentação vem causando certa concentração do setor pela aquisição de carteiras ou até mesmo de toda a empresa, sendo que estas negociações atingem a casa dos bilhões de reais. Essas situações encontram nas sociedades cooperativas médicas e odontológicas peculiaridades que divergem destas facilidades de negociação. / Globalization, financial and political stability and current degree of economical development that Brazil are living (because of these condition Standard & Poor’s gave to Brazil the classification of investment grade on April 30th, 2008) combined with Brazilians income degree are converting Brazil in an attractive market for outside capital. Private health sector regulamentation which started with the Brazilian law number 9656 from 1998, and the creation of Agência Nacional de Saúde Suplementar – ANS (in 2000) let this sector to attract curiosity and nowadays the attention of big stakeholders. Medical and odontological cooperatives have important participation in this market with signification part in share – like 40% on its set. The regulamentation bring on a concentration in the sector by portfolio purchase or until same all firm acquisition – that involves trillion of Brazilian reais. These situations find on medical and odontological cooperatives quirks that diverge from negotiations facilities.

Die Einführung des GKV-FQWG sorgt für einen verstärkten Wettbewerbsdruck innerhalb des Systems der gesetzlichen Krankenkassen. Bestehen hohe Anreize zur Risikoselektion, so kann dieser Druck in einen vermehrten Kampf um vermeintlich vorteilhafte Versichertengruppen führen. Die Studie stellt heraus, welche Anreize zur regionalen Risikoselektion unter einem differenzierten Risikostrukturausgleichssystem vorliegen und gibt einen Einblick in die Bedeutung des Problemfeldes. Hierfür werden regionale Versichertenstrukturen gegenüber ihrem geographischen Risikopotential mittels räumlicher Autokorrelationsanalyse untersucht.