The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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OHE Consulting Report for PhRMA 5 January 2011 Currently, services are offered by more than 64,000 primary care units (performing 2.7 billion ambulatory visits per year), and 5,900 hospitals (performing 12 million hospital admissions). Providers are paid on a fee-‐for-‐service basis for ambulatory care, including outpatient visits, exams and ambulatory procedures. Currently, there are a large number of procedure codes for these services in SUS. For inpatient hospital care and for cancer treatment, facilities are reimbursed under a prospective payment system, using diagnosis-‐related groups (DRGs). Hospital providers, including physicians, are usually paid a salary. A1.3 Private Health Care System Financing Most of the financing for private insurance comes from employers and employees, who pay for different shares of private insurance costs. Individuals may also purchase individual health plans out of pocket. The maximum value to be charged for individual health plans is regulated by the National Agency for Supplementary Health (ANS). The premiums charged to companies for executive health plans are not regulated and open to negotiation between private HMOs and companies. That is why most HMOs are stimulating the growth of executive plans instead of individual plans. ANS also defines the prohibition of HMOs to refuse coverage for any patient due to their risk profile. Premiums may vary by age for individual plans. Provision and Reimbursement ANS defines every two years the list of procedures covered by private payers. As a general rule, all treatments registered in Brazil for the indications covered by International Classification of Disease codes and provided in ambulatory or in-‐hospital should be reimbursed by HMOs. Treatments received at home and oral drugs are not covered by the private system. Originally, when this rule was created, it did not cover drugs for high cholesterol, hypertension, etc., that could be purchased by patients out of pocket. There is now a controversy over oral drugs for oncology treatment due to their high cost and the impossibility of most patients to pay for these treatments out of pocket. Provision of services is through private hospitals and outpatient clinics that are dedicated providers to specific HMOs. Providers may be dedicated to more than one HMO, which is the usual practice. Individual physicians may also own their offices and provide outpatient visits to patients. In the majority of cases, services are charged on a fee-‐for-‐service basis. The reference reimbursement values for exams and surgical procedures come from reference lists like the Brazilian Hierarchical Classification of Medical Procedures (CBHPM) and the list of the Brazilian Medical Association (AMB99). Drugs and materials are reimbursed based on their listed Maximum Prices to Consumer registered by the Chamber for Regulation of the Pharmaceutical Market (CMED). Discounts over the reference values may be negotiated between HMOs and providers on a case-‐to-‐case basis. 74
OHE Consulting Report for PhRMA 5 January 2011 Daily hospitalization costs in ward and ICU are negotiated between HMOs and hospitals. Some HMOs are pressing hospitals to create “packages” for surgical procedures, in a DRG-‐like reimbursement system. But these values are not standardized and are negotiated between HMOs and providers. In private outpatient clinics, physicians are usually paid on a fee-‐for-‐service basis, receiving a percentage of the revenue they generated to the facility. In private hospitals, some physicians are paid with a salary and others are paid on a fee-‐for-‐service basis. Physicians may also charge patients extra fees out-‐of-‐pocket to perform specific surgeries. A1.4 Health Technology Assessment in Brazil Overview As reflected in the chart in Figure 1, HTA is an integral and relevant part of a Policy for Management of Health Technologies created by the Secretary for Science and Technology of the Ministry of Health (MS) in 2003. There is an official guideline from the MS, published in the website of the Department of Science and Technology (DECIT) for the evaluation of technologies in the Brazilian Unified Health System (SUS) and the Supplementary Healthcare System (ANS; Private). Figure 1. MS, SCTIE (Elias, 2009) CITEC staff is financed by the budget of the Secretary for Science and Technology. The studies and analyses demanded by DECIT for ad hoc consultants (from public universities) are financed by 75
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