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MODELOS DE REMUNERAÇÃO NA SAÚDE

Modelos de remuneração na saúde 

por :José Luiz Bichuetti e Yussif Ali Mere Jr.

As características do Brasil e dos EUA diferem na infraestrutura da saúde e na cultura empresarial, dificultando a aplicação aqui das soluções de lá

Modelos como Capitation, Bundled Services e DRG têm sido desenhados e aplicados, ainda de maneira exploratória, para mercados mais evoluídos, cujo sistema de saúde difere do brasileiro. No Brasil o sistema privado de saúde remunera prestadores de serviços pela quantidade de procedimentos e não pela qualidade. Primeiro porque o foco está na doença e não na prevenção de suas causas. Segundo, porque a preocupação predominante está na forma de remunerar, na redução imediata de custos e não no resultado final do serviço assistencial prestado.

As negociações de preços de procedimentos assistenciais entre prestador e o plano de serviços de saúde é um dos principais entraves no avanço da relação entre eles no Brasil. Atrelar qualidade a custo não é fácil de equacionar em qualquer segmento empresarial, mais complexo ainda na saúde.

Esta edição traz artigos de mestres do tema, Porter/Kaplan e James/Poulsen, defendendo seus enfoques para remuneração dos serviços de saúde. Analisamos a aplicabilidade desses modelos juntamente com o Fee for service (FFS), o modelo mais utilizado aqui, e o DRG, emergente.

Capitation (per capita)
Prestadores recebem um valor fixo por mês, por pessoa coberta, o qual remunera todos os serviços de saúde ao longo de um período. O valor pode ser ajustado conforme necessidades específicas.

Depende de informações relacionadas aos riscos populacionais geograficamente distribuídos, requer sólida e complexa base estatística das enfermidades, região por região, faixa etária, raça, sexo e outros segmentos. Ao ser estabelecido um valor por associado e definido um hospital para o atendimento, poderá haver variações nos procedimentos, o que exige revisões dos valores acordados. Prestadores podem também receber um bônus, ou sofrer uma penalidade, dependendo da evolução dos resultados — mas tanto um quanto outro são calculados sobre a base populacional. Se medir qualidade já é complexo, mais ainda sobre uma base populacional com limitados dados estatísticos e sobre a qual o prestador não tem controle.

Os pacientes não estão preocupados com resultados populacionais, e sim com suas próprias necessidades, e a liberdade de escolher o prestador dos serviços de saúde. É fato que esse tipo de escolha começa a sofrer certas restrições: as fontes pagadoras passaram a limitar certos serviços a determinados prestadores, ou a facilitar aprovações de procedimentos para hospitais que lhes são mais convenientes. Mas, ainda assim, o paciente tem certo grau de liberdade.

Já tivemos no Brasil tentativas de aplicação do Capitation, porém sem resultados práticos, pois as estatísticas existentes não respaldam o modelo e não há a preparação adequada, seja de prestadores, seja de pagadores dos serviços. Esse modelo seria mais aplicável à rede pública, e um conceito semelhante tem sido utilizado para pagamento a hospitais privados que atendem pelo SUS, ainda assim com falhas, concentrando a avaliação de desempenho somente em índices quantitativos.

Bundled services
O prestador recebe um valor acordado com a fonte pagadora pelos serviços prestados ao paciente ao longo de todo o tratamento de uma condição específica (por exemplo, insuficiência cardíaca, diabetes).

É uma das modalidades do P4P — Pay for Performance, que permite usar incentivos com base em desempenho, não apenas financeiro.

Os prestadores têm, portanto, responsabilidade pelo ciclo completo do tratamento de determinada condição. O modelo leva em conta a melhoria do desempenho dos tratamentos, tanto em economias como em qualidade, e isso requer uma base de dados sobre o histórico do paciente e da população. Aqui também o risco recai sobre o prestador, e não é compartilhado pela fonte pagadora.

O modelo defendido por Porter/Kaplan poderia ser mais aplicável. É, porém, complexo para implementação e demandaria grande esforço, boa vontade e colaboração entre as partes envolvidas, num mercado onde os stakeholders se fecham cada um dentro de sua muralha. Em palestra proferida no Brasil, Porter disse que esse método exigiria um volume maciço de informações sobre a evolução populacional e suas doenças para viabilizar análises evolutivas dos resultados, em qualidade e economia; essa base de dados dependeria de contínua troca de informações entre prestadores de serviços.

O prestador de serviços precisaria estar bem estruturado porque a sua rentabilidade e a fidelidade do pagador dependem de seu desempenho, no qual redução de custos operacionais e colaboração interna são fundamentais. Esse sistema requer especialização do hospital, como nos exemplos citados por Porter/Kaplan. No Brasil, a predominância é de hospitais gerais; há poucos especializados e alguns já se abrem para outras especialidades. Em hospitais de corpo clínico aberto esbarra-se em interesses particulares dos médicos, categoria profissional que, pelas próprias características da formação, é pouco propensa a “trabalhos em equipe”, mas da qual depende fundamentalmente a notoriedade de todo hospital.

Diagnosis Related Groups (DRG)
Neste modelo se remunera mediante um único pagamento para um conjunto de serviços prestados, conforme o diagnóstico.

Tem como base a CID (Classificação Internacional de Doenças), que padroniza a codificação de doenças e outros problemas relacionados à saúde. Ela fornece códigos relativos à classificação de enfermidades e de sinais, sintomas, aspectos anormais, queixas, circunstâncias sociais e causas externas de ferimentos ou doenças.

Este modelo desconsidera o ciclo completo de atenção para o tratamento da doença, e os pagamentos são feitos separadamente, a cada especialista, o que pode descoordenar o serviço. Tem a vantagem de homogeneizar as categorias de doenças, e está sendo usado no Brasil para a definição de pacotes de serviços dentro do modelo Fee for service. Exige flexibilidade para ajuste de preços ao longo do processo.

Tanto no Bundled Services quanto no DRG há barreiras para precificação, pois há variações nas comorbidades, o que se reflete em variações nos diagnósticos. Procedimentos mais simples e previsíveis (apendicite, parto e outros) poderiam ser precificados sem risco de grandes variações nos procedimentos. Outros, mais complexos ou de natureza clínica, teriam maior dificuldade, pois sua variabilidade é maior. Num país de grande extensão geográfica e de desigualdades socioculturais regionais, a precificação teria de ser regionalizada, pois as incidências de doenças variam entre as regiões. No interior falta mão de obra médica; há localidades nas quais há um ou dois especialistas por tipo de enfermidade, ou nenhum. Como incentivar os médicos e medir desempenho quando eles e seus hospitais são únicos no local?

Fee for Service (FFS)
Modelo utilizado há décadas no Brasil. O prestador é remunerado por procedimento. As partes estabelecem previamente uma tabela de preços por procedimento ou conjunto deles.
Os valores praticados para os mesmos tipos de procedimento variam amplamente entre diferentes prestadores e pagadores. O desempenho não é levado em conta, os custos reais raramente
o são e os valores ficam condicionados aos poderes de barganha. Remunera-se a quantidade, não a qualidade; reinternações decorrentes de evoluções clínicas ou erros médicos são novamente remuneradas.

Este modelo tem estimulado a aplicação de glosas pelos pagadores, baseadas em recursos técnicos ou administrativos, ou aplicadas simplesmente de forma linear; elas se transformaram num dos principais instrumentos de pressão por parte das fontes pagadoras. Há, entretanto, operadoras que tentam evoluir para um modelo de diária compacta, que reduziria o custo administrativo de pré-análise de contas hospitalares, auditorias médicas e glosas. (Glosa é o não pagamento de valores referentes a atendimentos, medicamentos, materiais ou taxas cobradas pelos prestadores por falta de documentação adequada ou incorreção dos valores cobrados, entre outros fatores.)

O que emperra a adoção de um modelo adequado a prestadores e pagadores?

A obtenção de consenso sobre um modelo de pagamento adequado ao Brasil esbarra em alguns obstáculos:

  • Prestadores são pulverizados pelo país, e mesmo nos grandes centros são poucos os grandes complexos de serviços de saúde. Não há união entre os prestadores que possibilite um trabalho conjunto destinado a obter um modelo benéfico a todos. Impera o individualismo.
  • Fontes pagadoras parecem não estar dispostas a assumir riscos de mudança de modelo. Com maior poder de barganha do que as centenas de prestadores independentes, elas se acomodam com o status quo do FFS, pressionando por preços baixos. A Agência Nacional de Saúde Suplementar (ANS) incentivou a formação, em 2013, de gru-
    pos de trabalho entre hospitais e fontes pagadoras para debater possíveis soluções; o empenho foi descontinuado pela ausência de participantes. Dito dessa forma, parece que a “culpa” recai somente sobre os pagadores; vale, porém, destacar que eles também sofrem pressões decorrentes de aumentos de sinistralidades, impactando seus resultados, transformando-se em um dos principais influenciadores de seu modo de operação
    e negociação.
  • Muitos médicos trabalham em diferentes hospitais e não são fiéis a eles. Atendem a vários pacientes por hora para compensar a baixa remuneração e solicitam exames em excesso, seja por não dedicar tempo a uma análise clínica aprofundada do paciente, seja por falta de segurança. A forma como são contratados desestimula-os a desenvolver dedicação à instituição; eles são executores, e não gestores de saúde preocupados com todo o ciclo de tratamento dispensado aos pacientes.
  • Esses modelos exigem regras claras para seu adequado funcionamento e padronização de processos e insumos para uma segura formulação de preços. Deixam, também, um risco para o prestador quando este assume as responsabilidades pelo financiamento e pela qualidade do serviço prestado, além de exigirem envolvimento médico para que o desfecho clínico seja o melhor possível.
  • Ações como a implantação de uma plataforma disponibilizada pela fonte pagadora que possibilite ao médico acompanhar a trajetória do paciente na rede credenciada poderia reduzir o número de solicitações de exames e/ou de repetições de tratamentos sem bons resultados, sobretudo aos doentes crônicos. O sistema TISS — Troca de Informações na Saúde Suplementar —, implantado por iniciativa da ANS, está formando uma base de dados, porém seu uso ainda é restrito. Como diz Kaplan, “o que não é medido, não é gerenciado”.

Soluções podem existir, mas demandam um esforço conjunto entre os atores. Alterar simplesmente o modelo de remuneração sem a conscientização de que é necessário haver mudanças de atitude e de cultura assistencial e empresarial é buscar solução de curto prazo que arrastaria para o futuro as mesmas mazelas do sistema atual.

José Luiz Bichuetti foi CEO de empresas de diferentes setores, como complexos hospitalares e uma operadora de planos de saúde. Cursou o OPM-Owners/Presidents Management Program, da Harvard Business School. Autor do livro Gestão de pessoas não é com o RH.

Yussif Ali Mere Jr. é presidente da Federação dos Hospitais, Clínicas e Laboratórios do Estado de São Paulo (FEHOESP) e vice-presidente da Confederação Nacional de Saúde (CNS). Diretor executivo do Grupo Lund de Nefrologia.

http://hbrbr.uol.com.br/modelos-de-remuneracao-na-saude/

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  725. Prominente Musikschaffender haben sich für
    Samstag, 16. Juli, angesagt: Ab 19.30 Chronometer wird die
    allerseits geschätzte All-Star-Ensemble „Wir 4“
    aufwärts jener „Bühne Donaupark“ (22., Arbeiterstrandbadstraße 122) Chip Zuhörerinnen ferner Zuhörer inkl.
    einer „wienerischen“ Musik-Live Event mitreißen. Erreichen könnt ihr den Kinderspielplatz durch Deutsche Mark Automobil am besten durch die Arbeiterstrandbadstraße Oder Chip Donauturmstraße.
    Die BotschafterInnen dieser sechs lateinamerikanischen Staaten versammeln einander an Bolivars Geburtstag – Montag,
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    bei dessen Mahnmal nahe DEM Donauturm. Vorab dem Donauturm gibt es einen großen Stellplatz.
    Gleich längst bestimmte der 252 m hohe Donauturm Chip Horizont ringsherum um den Donaupark überdies
    bot mit Deutsche Mark drehbaren Speisegaststätte in 170 m den höchsten Aussichtspunkt Wiens.
    Tuttlingen sz Der Rotary Club Tuttlingen hat am
    Samstag jener Stadt Tuttlingen ein neues Spielgerät im Donaupark gewähren. Zu diesem Zeitpunkt wurde sogar das höchste Gebäude Wiens, der Donauturm,
    im Park errichtet. Ein naturverbundener Park mit allem
    Bequemlichkeit eines modernen Campingplatzes. Die letzte
    U-Bahn fährt aufs Ganze gesehen gemäß Mitternacht
    zurück in Strecke City.

    Geradeaus sieht man den Anbruch vom Landstraßer Gurt in Marschroute Wien Zentralstation. ECU PLAZA 5
    & 6 am Wienerberg – Tendenz NRW. Am Abend innehaben unsereins uns
    alsdann im platzeigenen Gastwirtschaft “kulinarisch” verwöhnen gewähren! Zu In-Kraft-Treten sein Eigen nennen wir
    himmelweit erfreulich contra gehalten, aus Weitschüssen gelang immerhin den Celtics die 2:0 Anführung.

    Am Finale gelang den Celtics noch welcher Anschlußtreffer, was unsern Triumph
    nunmehr un… mehr gefährdete. Zwar abgeschlagen Qando (ein) bisschen Datenmaterial auch weil Routen Können Neben…

    im WLAN vorgeladen werden, Chip Einsatz eines Datentarifs ist aber vor allem für Besucher aus anderen Ländern empfohlen. Prêk, welches sind Raffael Müller, David Häberlein nebst Andreas Mayr.
    Auf Basis von kombinieren schnellen Spielzug kann dasjenige Tornado nützen ebenso erzielt das Treffer.

    Krawatte – das sind Christoph Mayer, Florian Klose,
    Hans Schnürer, Dominik Hauf, Johannes Winkler ferner
    Oliver Schnürer. Selbst die Donau Innenstadt ist ein qualitativ
    hochwertiger Wohnraum zum Vorteil von allerlei Wienerinnen noch dazu Frankfurter Würstchen. Es
    werde noch untersucht, ob dieser 21-Jährige zum Besten von andere Taten verantwortlich sei, erklärte Pogutter.

    Jene kann in Hotels, jener Tourist-Info (Albertinaplatz) oder an den Verkaufsstellen der Frankfurter Würstchen Linien erworben Ursprung.
    Mio. Menschen, sondern nebensächlich von Seiten einer Vielzahl
    verschiedenster Tierarten – alles andere als wenige unterhalb sind selbst aufwärts welcher roten Gliederung der
    gefährdeten Arten zu (zufällig) begegnen! Welche Herkunft
    von Blank putzen weiterhin Touristen gerne zum Holen besucht.
    Benachrichtige mich über neue Beiträge mit E-E-Mail-Nachricht.
    Die Gästebewertungen Zustandekommen von anderen Reisenden aus Deutschland verfasst.
    Im Vordergrund ist der Kreuzungsbereich vom Ring zusätzlich zu DEM Ringturm zu erinnern. So wurde aus
    Anlass des Besuchs von Seiten Kirchenfürst Johannes Paul II.
    Voran rechts von dem Bild verläuft Chip Mariahilferstraße stadteinwärts wo auch Chip Fußgängerzone
    beginnt. Bootsverleih nebst Picknickkorb – einschließlich Füllung – gibt es dort.
    Auf Basis von der anfänglichen Bangigkeit des Gegners außerdem dieser drückenden Hitze hätte ein Führungstreffer dies Hasardspiel echt verschiedenartig
    Figur lassen können. Lasst Millionen Blumen strotzen! Je länger das Hasardspiel dauerte
    desto mehr ging DEM Club die Atem im Übrigen Lust aus.
    Kongressbad, 1160, Julius-Meinl-Gasse 7a, 486 11 63 – Chip funktionale Holzarchitektur der Zwischenkriegszeit steht bei Denkmalschutz.
    Chip Wien-Karte (21,90 €, Pegel 2014), einschließlich solcher man 72 Stunden lang alle öffentliche Fahrzeug Ziel kann auch weil
    Ermäßigungen seitens 10 – 20 % neben den Museen, Sehenswürdigkeiten,
    Stadtführungen, usw., erhält. Durch den Fernzügen jener ÖBB zum Zentralstation Oder zum
    Station Meidling; Fahrtdauer ca.

    Kilometer nicht zuletzt 20 Fetzen Rikscha inbegriffen dieser Beförderungsmöglichkeit für je zwei
    Menschen. In dasjenige historische, barocke
    Innenstadt mit seinen zahlreichen Shopping- und Sightseeing-Möglichkeiten, sind
    es alleinig wenige Gehminuten Chip Donau in Richtung Quelle.
    Es sieht so aus, qua hätten wir keine spezifische Note zu Donaupark, welches eine Wegbeschreibung
    aufwändig Machtfülle. Wien-Hütteldorf; wird infolge Regionalzüge ebenso wie
    den privaten Fernverkehrszug Westbahn angefahren, welcher
    ist, divergent als jener Westbahnhof, direkt ansonsten umsteigefrei über
    die Haltestelle “Hütteldorf” der U-Bahn-Feld 4 zugreifbar.
    Frankfurter Rathaus: Rathausplatz neben Burgtheater mit 10 verschiedenen Kamera-Perspektiven. Online einbegriffen der Straßenbahnlinie
    1, Station Hetzgasse. Kinder lernen die Mannigfaltigkeit von Rosen kennen, welche sehen ebenso duften ebendiese.
    Moderiert wird der Abend vonseiten Alexander Kunz,
    Redakteur bei hitradio rt1. Aber auch zum Sonnen, Picknicken Oder einfach
    zum Ballspielen ist es gegenständlich schön, da es fassbar im Überfluss Sitzgelegenheit
    gibt. Augarten Typ ist Gruppenbezeichnung Augarten: Bedeutender
    Barockgarten im 2. Department. Gefecht um Freiräume seit den 70ern, 2012 (Kuratorin, gemeinsam inkl.
    Werner Michael Schwarz). Marken-Kochstube möbliert – Siemens Einbaugeräte, Designbad,
    Börse in allen Räumen (Kurbad – Fliesen).

    Zur Argumentation gab dieser 18-jährige Fahranfänger an, dass
    er dachte, dass ein „Freund“ hinter ihm herfuhr anhand welchem er
    gegenseitig ein Wettlauf hätte aushändigen wollen, so Chip Polizei.

    Weiterhin wahrscheinlich eine dieser ruhigsten: Abgesehen von Seiten den Bürger dieser Donaucity scheint
    gegenseitig nun allein Seltenheitswert haben jemand hin zu (sich) verfahren. Zu Händen die Gesamtheit.
    Eigenarten von Seiten Hausbesetzungen darüber hinaus Kämpfen um
    selbstverwaltete Kulturzentren in Wien, in: Martina Nußbaumer, Werner Michael Schwarz (Hg.): Belegt!
    Beim Lightrun kommt es un… auf Chip Finalrunde Zeit,
    sondern um Amüsement ja sogar ein tolles Gemeinschaftsgefühl an. Eigen am
    Samstagvormittag quillt dieser Marktgebiet von Einkäufern auch Schaulustigen hoch.
    Solcher Heißes Würstchen Christkindlmarkt darüber hinaus als nächstes
    ein Freiluft-Eislaufplatz geheißen Wiener Eistraum (sich) weiden Einheimische
    außerdem Gäste im Winter. Und in jener Gußhausstrasse wird eifrig gebaut noch dazu inbegriffen der Webcam hat man kombinieren direkten Blick von dem Dach in den Hinterhof zur
    Baustelle. Die drei (Schlaf-)zimmer sind essentiell vom Gangart aus zu begehen. Genießen Selbige existent in Ruhe einen Verlängerten,
    eine auffällig österreichische Kaffeespezialität!

    Segelschule Hofbauer, Obere Konrad Adenauer Donaustrom.

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