Introdução: Um dos impactos sociais do envelhecimento diz respeito à oferta e demanda de serviços de saúde. O sistema brasileiro garante a prestação de serviços públicos em caráter universal e admite a participação do mercado na provisão de tais serviços. Assim, todo cidadão é usuário potencial de provedores de serviços financiados pelo Estado e pode, simultaneamente, usar provedores de natureza privada. Objetivo: Identificar a ocorrência de mudança de provedor prioritário de serviços de saúde, bem como características socioeconômicas e epidemiológicas e respectiva associação com a condição de ter ou não ter plano de saúde, na população idosa do município de São Paulo, no período 2000 / 2006. Material e método: estudo de coorte desenvolvido no âmbito do Estudo SABE (Saúde, Bem-Estar e Envelhecimento). A coorte iniciou-se em 2000 com 2.143 participantes de 60 anos e mais e, em 2006, contava com 1.115 pessoas. A variável dependente é ter plano de saúde e as independentes abrangem características sociais e demográficas; morbidade referida; autoavaliação de saúde; atividades básicas de vida diária; ações de prevenção e uso de serviços de saúde. Os dados, obtidos por meio de entrevista domiciliar, foram analisados de forma descritiva e pelo desenvolvimento de um modelo de regressão logística por passos (stepwise). Resultados: Há diferenças, favoráveis aos titulares de planos, nas variáveis renda, escolaridade e condições de vida pregressa. O grupo sem planos privados realizou menos prevenção contra neoplasias e mais contra doenças respiratórias; esperou mais para ter acesso a consulta de saúde; realizou menos exames pós consulta; referiu menor número de doenças; teve maior proporção de avaliação negativa da própria saúde e relatou mais episódios de queda. Os titulares de planos privados relataram menos dificuldades no desempenho em ABVD e menor adesão à vacinação. Dentre os titulares de planos que se internaram, em 2000, 11,1por cento tiveram sua internação custeada pelo SUS. Em 2006 essa proporção se eleva para 17,9por cento . A única enfermidade associada à condição de titular de plano privado foi a osteoporose. Não houve mudança significativa entre provedores prioritários de serviços de saúde. Conclusão: as associações encontradas relacionaram-se mais às questões sociais e demográficas e ao uso de serviços do que às condições de saúde dos indivíduos / Background: Population aging influences the offer and search for health services. The Brazilian health system (Sistema Único de Saúde SUS) warrants universal access to public health services and allows the participation of the private sector. Thus, each and every citizen is a potential user of services both provided by the State and by the private sector. We assume that private health insurance holders will have their health services preferentially provided by the private sector. Objective: To identify the occurrence of changes in priority health care provider, as well as socioeconomic and epidemiologic characteristics associated with having or not private health insurance in the elderly population in the city of São Paulo from 2000 to 2006. Methods: retrospective cohort study carried out as part of the Survey on Health and Wellbeing of Elders (SABE Saúde, Bem-estar e Envelhecimento). This cohort started in 2000 with 2,143 participants aged 60 years and, in 2006, had 1,116 participants. Having a private health insurance is the dependent variable and independent variables include sociodemographic characteristics; referred morbidity, self-assessment of health, basic activities of daily living (BADL), preventive actions and the use of health services. Descriptive analysis and stepwise logistic regression were used to assess data collected in home visits. Results: There were significant changes in income, scholarship and earlier life conditions in favor of insurance holders. The group that had no private health insurance was less subjected to cancer and more subjected to respiratory disease prevention, waited longer for health appointments, did less postappointment examinations, had a more negative self-assessment of health and reported higher frequency of falls. Private health insurance holders reported less difficulty to perform BADL and lower adhesion to vaccination campaigns. Among holders that were hospitalized, 11.1per cent had their medical expenses paid by SUS in 2000 and 17.9per cent in 2006. The only morbidity associated with being a private health care insurance holder was osteoporosis. There were no significant changes in priority health provider throughout time.Conclusion: The study population/group tended to keep the same type of health care provider and associations found were more related to socio-demographic characteristics and the use of services than with health conditions of the elderly

The theses is referring to The Comparison of Health Insurance Systems in the Czech Republic, Germany, Switzerland and the Neetherlands. It is focusing on three main components of the medical insurance system, the insurance companies, the healthcare providers and the insured parties. Each of these components has a significant role within the medical system and as their representation in distinct areas is quite broad, I prefered to choose the key areas where the medical insurance figures the most. Each chapter characterises one of the main components of the medical insurance system. First two chapters are the introduction and the models of financing of different medical systems. Third chapter depicts the main characteristics of the insurance system in each country. Fourth chapter names the rights and the duties of the insured person. Fifth chapter is acknowledged to the insurance companies and their role in the financement of the medical system. The last component of the medical system, the health care providers, are defined in the sixth chapter. The conclusion is attributed to the comparisson between the countries regarding the components listed above. The main goal of the theses is to present the differences between the health insurance systems and to evaluate the advantages and disadvanteges in...

The aim of my thesis was to examine people{\crq}s and professionals{\crq} opinions on introduction of the regulatory health fees. Within the scope of the two sub-targets, I tried to find out the amounts of the regulatory health fees acceptable for the citizens and something about the possibility to arrange a private health insurance. I briefly described the system of the public health insurance and I mentioned the system of the regulatory health fees and the annual protection limit in more detail in the theoretical part of the diploma thesis. In order to compile the thesis I used the method of questioning which I carried out by collecting data using a questionnaire and the method of the secondary analysis of data. Two statistics groups {--} general public and professionals from the South Bohemian Region - were defined for the research part. Based on the available literature, I established four hypotheses of which the first three were confirmed and the fourth one was disconfirmed by the research. The research revealed differences in opinions and perception of the regulatory health fees between the individuals and general public and professionals. The citizens{\crq} awareness {--} which still has its deficiencies as the questionnaire survey revealed {--} has definitely influence on the opinion on the regulatory health fees. The thesis could be used to increase the awareness of the system of the regulatory health fees and the annual protection limit, for lectures, eventually the respondents{\crq} replies and the research results could be taken into consideration when amending the existing Act No. 48/1997 Coll., on Public Health Insurance.

This thesis is aimed at learning selected aspects of the private health insurance system in OECD countries and its co-existence side by side with the public health insurance. Introductory chapters describe theoretic starting points and principles of functioning of the health insurance system in harmony with existing models of the healthcare policy. The analytical part of the thesis, using qualitative methods of investigation, deals with the development and the current state of the system of the health insurance in the Czech Republic from 1989 and characterizes briefly major problems being encountered and solved. Furthermore, the thesis maps trends of the health insurance in selected OECD countries, showing issues within the structure of healthcare system expenses in countries followed and their influence on the system of the health insurance. The thesis is also informing about present problems on the private health insurance market in OECD countries precisely as described in a study made by the Organization for Economic Co-operation and Development. The final chapter compares the mentioned health insurance systems from the point of view of co-payment and co-existence.

The thesis is dealing with financial aspects of the U.S. health care system. The main reasons are excessively high costs and less beneficial outputs of the system compared to other developed countries. The topic is more than up to date especially with regard to the latest changes in American health care and the neverending discussion about the necessity of further reforms aiming especially at fiscal sustainability of the system.The introduction is devoted to a brief description of basic models of health care system. It also introduces the approach of the United States to health care and provides an overview of the structure and participants of American health care. Moreover, the thesis provides details about the latest reform of the system. The main objective of the thesis is analysis of main factors that contributes to high growth of health care costs. Technological development, consolidation of markets and ineffective setting of health care reimbursement are identified as some of the main contributors to high cost in the U.S. health care system.

Die Ausgaben für das Gesundheitssystem sind in den vergangenen Jahren kontinuierlich und stärker als das Bruttoinlandsprodukt gestiegen. Auch für die Arzneimittelkosten als relevante ökonomische Komponente im Kontext der gesamten Gesundheitskosten war für den Betrachtungszeitraum der Jahre 2008 - 2013 ein nahezu stetiges Wachstum zu verzeichnen. Zwischenzeitliche regulatorische Maßnahmen konnten zwar eine kurzzeitige Dämpfung dieses Wachstums im Jahr 2011 erreichen, in den nachfolgenden Jahren zeigte sich jedoch wieder ein steigender Kostentrend. Eine differenzierte Analyse der Arzneimittelkostenentwicklung ergibt verschiedene Einflussfaktoren. Hier sind soziodemographische Merkmale der betrachteten Kollektive, ökonomische und technologische Parameter im Umgang mit Arzneimitteln sowie die politisch-rechtliche Regulierung in den jeweiligen Kostenträgersystemen PKV und GKV zu nennen. Nicht zuletzt spielt die individuelle Situation der Patienten als Kombination aus Faktoren wie Gesundheitszustand, Risikofaktoren, Lebensstil und Therapieadhärenz eine zentrale Rolle in der effektiven und effizienten Anwendung von Arzneimitteln. Die im Rahmen dieser Dissertation detailliert analysierten Krankheitsbilder Hypertonie, Diabetes mellitus und Fettstoffwechselstörungen sind jeweils durch eine hohe Prävalenz gekennzeichnet und treten im Kontext des Metabolischen Syndroms oft kombiniert auf. Durch direkt entstehende Behandlungskosten und indirekt verursachte Kosten aus Folgeerkrankungen haben die ausgewählten Krankheitsbilder ein besonderes gesundheitsökonomisches Gewicht und nehmen einen bedeutenden Stellenwert im Rahmen der aktuellen gesundheitspolitischen Diskussion ein. Das Ziel dieser Dissertation ist es, aufzuzeigen, wie sich die Arzneimittelkosten im Kontext des Metabolischen Syndroms in jeweils einem Versichertenkollektiv der GKV und PKV entwickelt haben. Hierzu wurde jeweils eine Datenbasis pro Kollektiv nach den Kostenparametern Arzneimittelkosten, Verordnungsmengen, Werte pro Verordnung sowie den soziodemographischen Parametern Versichertenanzahl, Altersgruppen, Geschlecht und Postleitzahlenbereiche (nur für PKV-Kollektiv) ausgewertet. Der Untersuchungszeitraum ergibt sich aus einer vergleichbar auszuwertenden Datenbasis für beide Kollektive für die Jahre 2008 - 2013. Das Ergebnis der Kostenanalyse sind Wachstumsraten für alle genannten Kostenparameter zu den jeweiligen Subsegmenten der Kollektive. Zusammenfassend lässt sich feststellen, dass die Entwicklung der Arzneimittelkosten und ihrer Komponenten (Mengen und Werte) in allen untersuchten therapeutischen Hauptgruppen für beide Kollektive während des Betrachtungszeitraums 2008 - 2013 zwar teilweise unterschiedliche Verläufe zeigt, in der Gesamtbetrachtung aber sehr ähnliche Werte liefert. Bei den Lipidsenkern ist die Deckungsgleichheit der Wachstumswerte am größten. Auffällig ist dabei, dass die Werte pro Verordnung im PKV-Kollektiv gleiche oder sogar geringere Wachstumsraten aufweisen als im GKV-Kollektiv. Obwohl der Übergang zu generisch verfügbaren Arzneimitteln in der GKV in der Regel viel schneller stattfindet und es im Betrachtungszeitraum eine große Dynamik auf dem Generikamarkt gab, resultierte daraus kein Unterschied zwischen den Kollektiven in dieser Betrachtung. Ein zentrales Ergebnis der durchgeführten Altersgruppenanalyse ist, dass nicht ausschließlich für die höheren Altersgruppen diskussionswürdige Entwicklungen zu verzeichnen sind, sondern auch die jüngste detailliert ausgewertete Gruppe der 40- bis 49-Jährigen auffällige Steigerungsraten bei einzelnen Untersuchungsparametern aufweist. Dieses Alterssegment hat zwar in der aktuellen ökonomischen Betrachtung möglicherweise ein noch geringes Gewicht innerhalb der Gesamtpopulation, durch die beobachteten Steigerungsraten besteht jedoch Anlass zu frühzeitigen Interventionen. Hier offenbaren sich Ansatzpunkte für einen veränderten Fokus bei der Konzeption zielgruppenbezogener Interventionsmaßnahmen. Auch wenn die Kostenentwicklung in den untersuchten therapeutischen Hauptgruppen im Betrachtungszeitraum relativ moderat verläuft, zeigt u. a. der überdurchschnittliche Anstieg der Verordnungsmengen die gesundheitsökonomische Relevanz der detaillierten Analyse von Arzneimittelausgaben. Diese Ausgaben stellen einen wichtigen Faktor im Kontext der gesamten Gesundheitskosten dar. Weitere Forschungsansätze, die Kosteneinflüsse durch Begleit- oder Folgeerkrankungen sowie Sekundärschäden der betrachteten Krankheitsbilder untersuchen, können einen zusätzlichen Beitrag zur langfristigen Finanzierbarkeit des Gesundheitssystems leisten.:1 Einleitung 1.1 Gesundheitsausgaben in Deutschland 1.2 Leistungsarten der Gesundheitsausgaben 1.3 Arzneimittelkosten 1.4 Das Metabolische Syndrom 1.5 Forschungsstand 2 Fragestellung 3 Daten und Methodik 3.1 Datenschutz und Datensensibilität 3.2 Datenquellen 3.3 Datenauswertung und –analyse 3.4 Limitationen 4 Ergebnisse 4.1 Charakterisierung und Entwicklung der betrachteten Kollektive 4.2 Entwicklung der Gesundheitskosten 4.3 Entwicklung der Arzneimittelkosten 4.4 Entwicklung der Verordnungsmengen und -werte 4.5 Gesamtkostenentwicklung nach Mengen- und Werteffekten 4.6 Entwicklungen in den umsatzstärksten therapeutischen Hauptgruppen 4.7 Entwicklungen für Antihypertensiva, Antidiabetika und Lipidsenker 5 Diskussion 5.1 Limitationen 5.2 Gesamtentwicklung der Gesundheits- und Arzneimittelkosten 5.3 Antihypertensiva 5.4 Antidiabetika 5.5 Lipidsenker 5.6 Übergreifende Handlungsoptionen 6 Ausblick 7 Zusammenfassung 8 Summary 9 Literaturverzeichnis 10 Abkürzungsverzeichnis 11 Tabellenverzeichnis 12 Abbildungsverzeichnis 13 Erklärungen zur Eröffnung des Promotionsverfahrens 14 Erklärung zur Einhaltung rechtlicher Vorschriften,

Esta tese analisa a trajetória, os desafios e as perspectivas da regulação em saúde suplementar, contextualizados num ambiente de grandes transformações do papel dos Estados nacionais e das relações entre a Economia e a Política no âmbito mundial e no Brasil. As interrelações entre economia e política são a base para importantes mudanças no papel do Estado brasileiro, do arcabouço regulatório e da regulação da saúde suplementar em particular. A tese tem início com o desenvolvimento de uma análise sobre o panorama político e econômico mundial, de modo a identificar suas influências sobre o Brasil e o setor de saúde brasileiro. À luz deste arcabouço analítico, é desenvolvido um detalhamento retrospectivo dos principais normativos que compuseram a regulação em saúde suplementar, editados por intermédio da Agência Nacional de Saúde Suplementar ANS. Para tanto, foi construído um banco de dados que servirá não apenas para a pesquisa da tese, mas para outros trabalhos a serem desenvolvidos posteriormente. O estudo desse material permitiu identificar uma trajetória da saúde suplementar marcada por três diferentes tônicas, que tem se desdobrado a partir da cena das grandes transformações mundiais. As conclusões aqui obtidas sobre a trajetória da regulação foram ainda apreciadas, por meio de pesquisa com todos os atuais e antigos dirigentes da ANS. Adiante, foi realizada uma breve análise dos efeitos produzidos por cada uma das tônicas anteriormente descritas, bem como discutidos os principais desafios que se colocam na ordem do dia na agenda da saúde suplementar no Brasil. É interessante destacar que discussão da perspectiva futura da regulação da saúde suplementar no Brasil se dá sobre um pano de fundo de profundas transformações no plano da política e das relações de hegemonia e poder na esfera global. Por fim, o trabalho aqui apresentado tem a finalidade de contribuir para o desenvolvimento do tema e sugerir aperfeiçoamentos de modo a aprimorar o planejamento, a gestão e a regulação da saúde suplementar, buscando relações público-privadas mais harmoniosas e eficientes no tocante à assistência e promoção da saúde. / This thesis analyzes the trajectory, challenges and prospects of private health insurance regulation in Brazil in a context of changing of hegemony and relationship between economics and politics. This scenario of economy and political change is the basis for the Brazilian State agenda on health regulation. This work analyzes the worlds economic and political landscape in order to identify its influence on Brazil and on the Brazilian healthcare industry. Based on this framework, we develop a retrospective analysis of the major private health insurance regulatory policies enacted by the Brazilian National Health Agency ANS. In this way, a database was built not only for research thesis, but also for later studies. Subsequent analytical study has identified three different waves in the Brazilian regulation trajectory. Results were, then, checked by all current and former ANS directors. This work, also analyses the effects of those three waves and discusses the main challenges of health insurance regulation agenda in Brazil. It is worth noting that discussions of future regulatory policies in Brazil take place on the grounds of critical changes in policy, power and hegemony over the world. Lastly, this work provides contribution to the development of the theme and suggests enhancements to improve planning, management and regulation of health, seeking more harmonious and efficient public-private relations in the field of disease prevention and health promotion.

Esta tese analisa a trajetória, os desafios e as perspectivas da regulação em saúde suplementar, contextualizados num ambiente de grandes transformações do papel dos Estados nacionais e das relações entre a Economia e a Política no âmbito mundial e no Brasil. As interrelações entre economia e política são a base para importantes mudanças no papel do Estado brasileiro, do arcabouço regulatório e da regulação da saúde suplementar em particular. A tese tem início com o desenvolvimento de uma análise sobre o panorama político e econômico mundial, de modo a identificar suas influências sobre o Brasil e o setor de saúde brasileiro. À luz deste arcabouço analítico, é desenvolvido um detalhamento retrospectivo dos principais normativos que compuseram a regulação em saúde suplementar, editados por intermédio da Agência Nacional de Saúde Suplementar ANS. Para tanto, foi construído um banco de dados que servirá não apenas para a pesquisa da tese, mas para outros trabalhos a serem desenvolvidos posteriormente. O estudo desse material permitiu identificar uma trajetória da saúde suplementar marcada por três diferentes tônicas, que tem se desdobrado a partir da cena das grandes transformações mundiais. As conclusões aqui obtidas sobre a trajetória da regulação foram ainda apreciadas, por meio de pesquisa com todos os atuais e antigos dirigentes da ANS. Adiante, foi realizada uma breve análise dos efeitos produzidos por cada uma das tônicas anteriormente descritas, bem como discutidos os principais desafios que se colocam na ordem do dia na agenda da saúde suplementar no Brasil. É interessante destacar que discussão da perspectiva futura da regulação da saúde suplementar no Brasil se dá sobre um pano de fundo de profundas transformações no plano da política e das relações de hegemonia e poder na esfera global. Por fim, o trabalho aqui apresentado tem a finalidade de contribuir para o desenvolvimento do tema e sugerir aperfeiçoamentos de modo a aprimorar o planejamento, a gestão e a regulação da saúde suplementar, buscando relações público-privadas mais harmoniosas e eficientes no tocante à assistência e promoção da saúde. / This thesis analyzes the trajectory, challenges and prospects of private health insurance regulation in Brazil in a context of changing of hegemony and relationship between economics and politics. This scenario of economy and political change is the basis for the Brazilian State agenda on health regulation. This work analyzes the worlds economic and political landscape in order to identify its influence on Brazil and on the Brazilian healthcare industry. Based on this framework, we develop a retrospective analysis of the major private health insurance regulatory policies enacted by the Brazilian National Health Agency ANS. In this way, a database was built not only for research thesis, but also for later studies. Subsequent analytical study has identified three different waves in the Brazilian regulation trajectory. Results were, then, checked by all current and former ANS directors. This work, also analyses the effects of those three waves and discusses the main challenges of health insurance regulation agenda in Brazil. It is worth noting that discussions of future regulatory policies in Brazil take place on the grounds of critical changes in policy, power and hegemony over the world. Lastly, this work provides contribution to the development of the theme and suggests enhancements to improve planning, management and regulation of health, seeking more harmonious and efficient public-private relations in the field of disease prevention and health promotion.

Cette thèse s’intéresse, en France, à la place de l’assurance maladie privée (ou complémentaire) dans l’organisation globale du système d’assurance, sous l’angle des inégalités sociales et de la solidarité entre les individus bien-portants et les malades. Elle étudie en particulier le rôle joué par l’assurance complémentaire sur l’accès aux soins, la mutualisation des dépenses de santé et le bien-être de la population. Les travaux menés dans cette thèse révèlent l’importance de l’assurance complémentaire pour accéder à des soins reportés dans le temps pour raisons financières. Ils montrent en revanche que, généraliser l’assurance complémentaire, dans le modèle actuel de co-financement des soins, ne permet ni de répondre à des objectifs d’équité ni-même d’améliorer le bien-être de la population. Ils révèlent en sus que l’assurance complémentaire induit une moindre mutualisation des dépenses de santé pour les plus malades et invitent à repenser son rôle dans le financement des soins. / This thesis deals with the place of private health insurance in the overall health insurance scheme in France, focusing on social inequalities and on solidarity between healthy individuals and sick patients. It particular, it addresses the role of private health insurance on access to health care, mutualization of health expenditure, and welfare. The results of this thesis reveal the key role of private health insurance to access to care postponed over time for financial reasons. However, our results also show that generalizing complementary health insurance in the current health insurance scheme does not allow pursuing equity goals nor increasing welfare. They finally reveal that the mutualization induced by private health insurance appears relatively weak, compared to the one induced by public health insurance. They therefore encourage a change in the role of private health insurance in funding medical care.

Submitted by Bruno Araujo Ramalho (brunrama@hotmail.com) on 2017-03-14T18:02:34Z No. of bitstreams: 1 Dissertação - BRUNO ARAUJO RAMALHO - (versão final).pdf: 2077332 bytes, checksum: 0dd8154f4be3890a0c30271468fdb13f (MD5) / Approved for entry into archive by Publicação Direito Rio (publicacao.direitorio@fgv.br) on 2017-03-15T18:39:56Z (GMT) No. of bitstreams: 1 Dissertação - BRUNO ARAUJO RAMALHO - (versão final).pdf: 2077332 bytes, checksum: 0dd8154f4be3890a0c30271468fdb13f (MD5) / Made available in DSpace on 2017-03-23T12:17:19Z (GMT). No. of bitstreams: 1 Dissertação - BRUNO ARAUJO RAMALHO - (versão final).pdf: 2077332 bytes, checksum: 0dd8154f4be3890a0c30271468fdb13f (MD5) Previous issue date: 2017-02-07 / Procedural requirements related to decision making and justification of regulatory choices may have limited application under uncertainty, informational limitation and other obstacles that lead the regulator to adopt strategies to tailor decision making to reality. Based on this hypothesis, and considering the uncertainties and issues of high technical complexity related to the 'list of health care procedures and events in health care', the objective of the research was to carry out an exploratory analysis intended to identify limitations, obstacles and observable strategies in the elaboration and justification of these norms. For this purpose, it was adopt a methodology of qualitative analysis based on documentary research, which included different documents available through the National Regulatory Agency for Private Health Insurance and Plans (ANS) website in public consultations, in the Technical Group for reviewing the list of procedures and in the Committee on Regulation of Health Care (COSAÚDE). As a result, it was verified the hypothesis mentioned above, since the dynamics of the choice presents restrictions that lead the regulator to adopt different strategies to deal with. The obstacles related to 'decision-making' dimension arise from the complexity and uncertainties related to the medical evidences, informational limitations and from interferences of the Legislative Branch and the Judiciary. Regarding the giving reasons requirement, although it is possible to see a greater density of justification starting in 2013, the reasons and replies presented in a synthesized format often do not suffice to clarify all the issues that support complex choices. Among the proposals of the study, the regulator should to provide a more detailed record about the valuation and the operationalization of its methodology criteria. / Exigências procedimentais relacionadas ao processo decisório e à justificação de escolhas regulatórias podem ter sua aplicação limitada em cenários de incerteza, limitação informacional e demais obstáculos que levam o regulador a adotar estratégias para adequar a tomada de decisão aos recursos disponíveis. Partindo-se desta hipótese, a pesquisa teve por objetivo a realização de uma análise exploratória com vistas a identificar limitações, obstáculos e estratégias observáveis na elaboração e justificação do rol de procedimentos e eventos em saúde – eis que a elaboração do 'rol' é permeada por incertezas e por questões de alta complexidade técnica. Para tanto, adotou-se a metodologia de análise qualitativa baseada em pesquisa documental, que englobou diferentes anexos disponibilizados a partir do sítio eletrônico da Agência Nacional de Saúde Suplementar (ANS) em consultas públicas, no Grupo Técnico de revisão do rol de procedimentos e no Comitê Permanente de Regulação da Atenção à Saúde (COSAÚDE). Ao final, foi possível evidenciar importantes elementos que moldam ou restringem a tomada de decisão e a sua respectiva justificação. No âmbito dos resultados, os obstáculos relacionados à dimensão 'processo decisório' decorrem de diferentes fontes de incerteza, do volume (e complexidade) das informações e de interferências promovidas pelo Poder Legislativo e Judiciário – sendo observáveis diferentes providências do regulador para cada caso. No que tange ao dever de motivação, embora se percebam melhorias a partir de 2013, a apresentação de justificativas e réplicas segue um formato mais compactado e não contempla algumas questões metodológicas que servem como base para premissas elencadas pelo regulador. Dentre outras propostas do estudo, sugeriu-se que a agência disponibilize o amplo acesso a documentos ou relatórios que registrem, de forma pormenorizada, a operacionalização dos quesitos que integram a metodologia de decisão.