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Physicians often continue to prescribe brand-name drugs to their patients even when less expensive generic equivalents are available. In a 1994 study, Judith Hellerstein advances two hypotheses to explain this behavior. First, doctors may consciously conclude that certain brand-name drugs impart a relative therapeutic benefit that outweighs their higher cost. Second, physicians may choose to prescribe brand-name drugs without evidence of therapeutic superiority if neither they nor their insured patients bear the increased cost of these drugs. The second hypothesis implies that moral hazard is evident in physicians' prescribing behavior. Hellerstein's findings support neither hypothesis, but her estimation equation does not explicitly capture the effects of brand-name/generic price differentials and information diffusion on the probability of generic prescription. The author adapts Hellerstein's theoretical model to a modified estimation equation that incorporates these effects and uses it to create new estimates based on data on antimicrobial prescriptions from the 1994 National Ambulatory Medical Care Survey (NAMCS). Unexpectedly, the results appear to affirm both hypotheses. The evidence for moral hazard is particularly strong, as self-paying patients are significantly more likely than patients with Medicare or private insurance to be prescribed the generics that are cheapest relative to their brand-name counterparts. The author also finds that certain popular antimicrobial drugs such as amoxicillin and sulfamethoxazole/trimethoprim are prescribed in the same form (generic or brand-name) by most doctors to most patients. The market power exhibited by these preferred forms leads the author to conclude that they are "brands" in the economic sense. / Master of Arts

由於目前世界上已實施健康保險制度的國家均面臨到醫療費用不斷上漲的問題，導致保險財務難以負荷。根據許多研究皆發現一合理的醫療支付制度不僅可以改善財務之虧損，也足以影響到醫療服務的品質。 　　本論文主要是以勞保局所核付的六種眼、耳鼻喉疾病為研究對象，探討醫師對其診療行為的差異性，同時探討影響此差異性的因素；接著探討勞保甲乙丙表的實施對醫師診療行為的影響，最後加入醫師的薪資制度因素，一起探討對醫師診療行為的影響。而本研究最終的目的是要藉由對過去所實施的勞保支付制度的影響進行研究，以作為全民健保在制定醫療支付標準時的參考。 　　本研究的結果發現： 　　1.醫院特性（級別、屬性別）對各項醫療費用的影響十分顯著，反而病人特性（年齡、性別）對各項醫療費用的影響並不是非常顯著。 　　2.勞保甲乙丙表的實施，對於某些項目因支付標準的提高，使得本研究中的六種疾病在病房費、檢查費、手術費及費用合計方面，大多數都有明顯地上升；而藥品因取消依進價加成的支付方式，改以進價支付，且再支付定額的藥事服務費，故大多數疾病的藥劑費都有明顯地下降。 　　3.六種疾病的住院日皆有逐漸縮短的趨勢，對於醫療費用的節省而言，的確是一個好現象。 　　4.醫師薪資制度對六種疾病的住院日數及各項醫療費用皆有顯著性的影響，但由於調查各醫院醫師薪資制度的問卷設計在薪資制度的分類上未盡詳細，以致於所作的結果無法顯現出薪資制度對六種疾病有一致性的影響。 　　針對本研究的結果，提出幾點建議供後續研究者作為參考： 　　1.本研究的結果在藥劑費方面雖有明顯地下降，但未進一步探討病人在用藥數量及藥劑注射的情況是否有所改善，將來可針對此作進一步的探究。 　　2.本研究由於資料的限制度，無法將醫院特性間，以及與薪資制度間的交互作用納入複迴歸模式中，因此將來若有充分的資料，便可將這些一併考慮進去，使得迴歸模式更完整，結果更具說服力。

Submitted by Renata Lopes (renatasil82@gmail.com) on 2018-07-20T15:48:26Z No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-09-03T16:18:14Z (GMT) No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) / Made available in DSpace on 2018-09-03T16:18:14Z (GMT). No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) Previous issue date: 2018-06-29 / A tese tem por objetivo estimular a discussão, por meio de três estudos independentes, sobre os impactos econômico-financeiros das cesarianas desnecessárias no Brasil, estimando os custos, propondo estratégias para redução do procedimento quando desnecessário e investigando a hipótese de que obstetras induzem a demanda por cesariana. A epidemia de cesariana é um problema de saúde pública que onera financeiramente os sistemas público e privado de saúde e que desperdiça recursos que poderiam ser utilizados de maneira mais eficiente. O primeiro estudo estima o custo da cesariana desnecessária no Brasil. Tendo como base dados da pesquisa Nascer no Brasil, DATASUS, SIGTAP, UNIDAS e estimando por regressão logística, foi possível concluir que o custo da cesariana desnecessária é no mínimo R$ 10,5 milhões no setor público e R$ 17,6 milhões no setor privado, o que representa 1,6% a 6% dos gastos públicos com cesariana. O segundo estudo propõe mudança no modelo de assistência obstétrica que envolve alteração na jornada de trabalho, na forma de remuneração e no aumento da punição aos obstetras, como forma de inibir a prática de indução de demanda. A partir de referências na literatura, dados da AMB, DATASUS e da pesquisa Nascer no Brasil, atribuíram-se métricas para a utilidade do obstetra e utilizou-se uma simulação para sensibilizar as métricas de remuneração e ética profissional, permitindo observar o efeito na decisão do obstetra. Concluise que remunerar obstetras com salário fixo, introduzi-los na jornada de trabalho sob regime plantão e em equipe colaborativa e aumentar da punição pela prática antiética de indução de demanda são ações que podem somar a outros esforços para o combate à epidemia da cirurgia no Brasil. O terceiro estudo investigou a hipótese de indução de demanda por cesariana no Brasil. Com dados do DATASUS, CFM e da pesquisa Nascer no Brasil, foi possível descrever comportamentos da assistência obstétrica brasileira no que diz respeito ao volume de nascimentos por hora, processos éticos contra obstetras e a probabilidade de haver cesariana sem indicação clínica. As conclusões são de que o volume de nascimentos por cesariana no Brasil supera aos do parto vaginal em horários comerciais, que ginecologia-obstetrícia é a especialidade com maior volume processos ético-disciplinares no CFM, que a maioria das decisões dos CRM’s/CFM tem caráter reservado e que quando o trabalho de parto de mulheres de risco habitual, que se iniciou espontaneamente, é acompanhando só por médico obstetra, ocorre em dia de semana e o obstetra decidiu a via de nascimento no final da gestação, houve maior chance de cesariana, levando à suspeita da prática de medicina defensiva. / This thesis aims to stimulate the discussion, by means of three independent studies, of the economic-financial impacts of unnecessary cesarean sections in Brazil, estimating the costs, suggesting strategies to decrease this procedure when unnecessary and investigating the hypothesis that obstetricians induces the demand for this surgery. The cesarean sections epidemic is a public health issue that financially burdens both public and private health systems, wasting resources that could be used in a more efficient way. The first study estimates the cost of unnecessary cesarean section in Brazil. Basing on Birth in Brazil research, DATASUS, SIGTAP and UNIDAS data and estimating by logistic regression, it was possible to conclude that the cost of unnecessary cesarean sections is at least R$ 10,5 million in the public sector and R$ 17,6 million in the private sector, representing 1.6% to 6 % of public expenses with this procedure. The second study proposes a change in the obstetric assistance model that involves alteration in the working hours, in the remuneration forms and the increase of penalties to obstetricians, as way to inhibit the practice of demand induction. Starting from literature references, AMB, DATASUS and Birth in Brazil research data, a metric for the obstetrician utility has been attributed and a simulation to sensetize the metrics for remuneration and professional ethics has been used, allowing to observe the effects in the obstetrician decisions. It was concluded that remunerating obstetricians with a fixed wage, puting them in a on call working journey with a collaborative team and increasing penalties for the unethical practice of demand induction are means that can be added to other efforts to fight the epidemic of this surgery in Brazil. The third study has investigated the hypothesis of demand induction for cesarean sections in Brazil. With DATASUS, CFM and Birth in Brazil research data, it was possible to describe behaviors of Brazilian obstetric assistance regarding the amount of births per hour, ethical law suits against obstetricians and the probability of a cesarean section without clinical indication. The conclusions are that the amount of births by cesarean section in Brazil exceeds those of vaginal delivery during business hours, that gynecology-obstetrics is the specialty with the greatest amount of ethical-disciplinary law suits in the CFM, that most CRMs/CFM decisions have a reserved character and that when the labor of women on habitual risk, which started spontaneously, occurs on weekdays and is followed only by an obstetrician, and the obstetrician decided the birth path at the end of gestation, there was a higher chance of a cesarean section, leading to the suspicion of the defensive medicine practice.