2. La teoría de los paradigmas
Nivel
de
problemá2ca
social
Paradigma
I
Paradigma
II
t
Problema
en
Acción
del
Agotamiento
plenitud
paradigma
del
paradigma
Joel Barker. “Paradigmas”: Conjunto de ideas que determinan una forma efectiva de
resolver problemas.
3. Problemática en Ascenso
• Nueva Problemática:
– Longevidad saludable
– Enfermedades complejas y crónicas
– Costos y Financiamiento
– Inequidad
• Falta de Paradigma Adecuado
5. Longevidad y Salud
• AUMENTO DE LA
ESPERANZA DE VIDA
o C o n c e n t r a c i ó n d e l a s
defunciones en torno a la
senilidad
6. Esperanza de vida al nacer
Australia
Esperanza
de
vida
al
nacer,
OECD,
ambos
sexos
Austria
90
Belgium
80
Czech
Republic
France
70
Germany
Hungary
60
Japan
50
Mexico
años
Netherlands
40
New
Zealand
Norway
30
Poland
20
Portugal
Slovak
Republic
10
Sweden
Switzerland
00
Turkey
United
States
7. y World life expectancy more than dou- “hypothetical table promised an ultimate
Downloaded from www.sciencemag.org on
e bled over the past two centuries, from figure of 64.75 years” for the expectation
x- roughly 25 years to about 65 for men and of life both for males and for females. At
Duración de la Vida
e 70 for women (4). This transformation of the time, U.S. life expectancy was about
e the duration of life greatly enhanced the 57 years. Because Dublin did not have da-
v- quantity and quality of people’s lives. It ta for New Zealand, he did not realize that
y fueled enormous increases in economic his ceiling had been pierced by women
),
p
n
95
Australia UN
La expectativa de
vida podría estar
90 Iceland World Bank
g Japan Olshansky et al.
n The Netherlands UN
Fries, Olshansky et al.
85
lejos de su límite
r- New Zealand non-Maori Coale Coale & Guo
Norway
n- Sweden
World Bank, UN
Bourgeois-Pichat, UN
e 80 Siegel
Switzerland
Life expectancy in years
• La esperanza de vida
Bourgeois-Pichat
h UN, Frejka
s 75
e. aumenta:
i- 70
Dublin
Dublin & Lotka
e, – linealmente, 3 meses/año
ar 65 Dublin
desde hace 160 años.
-
r-
60
• Nadie demostró que la
d
ut 55 edad de fallecimiento no
g
e- 50 aumente.
s
45
1840 1860 1880 1900 1920 1940 1960 1980 2000 2020 2040 Jim Oeppen and James W. Vaupel. Broken
s- Year Limits to Life Expectancy. Science
e 2002;296:1029
d Fig. 1. Record female life expectancy from 1840 to the present [suppl. table 2 (1)]. The linear-re-
e gression trend is depicted by a bold black line (slope = 0.243) and the extrapolated trend by a
8. Compresión de la Mortalidad
C
Nº
Defunciones
A
B
Edad
• Avance
de
la
edad
media
de
mortalidad.
• Menor
dispersión.
9. Mortalidad Humana
Probabilidad
de
Morir
EDAD
Strehler
BL,
Mildvan
AS.
Science
1960;
132:14-‐21
10. Curvas de defunciones
Defunciones,
ambos
sexos,
cada
100.000,
año
2009.
Elaboración
propia
en
base
a
WHO
20.000
16.000
Argen2na
12.000
Japón
Angola
8.000
4.000
0
11. Curvas de defunciones
Defunciones,
ambos
sexos,
c/100.000,
a
parGr
de
los
35
años.
Elaboración
propia
en
base
a
WHO
(Japón
2009)
20000
Defunciones
cada
100.000
16000
12000
Argen2na
2009
Japón
8000
4000
0
• La
Argen2na
2ene
un
exceso
de
muertes
en
jóvenes
12. Longevidad y Salud
• LONGEVIDAD
PROLONGADA
o D i s m i n u c i ó n d e l a
mortalidad a edades
avanzadas
13. Retraso de la mortalidad
RE|Vol 464|25 March 2010
95
Sweden 1,800
USA Swedes 100+
Japan
• Postérgase mortalidad 1,600
Japanese 105+
90
a edades avanzadas. 1,400
Number of females aged 100+ or 105+
85
• X5 y X10 1,200
X5
– Edad a 1,000que quedan
la
Age (yr)
80
5 y 10 años de vida
800
75
promedio.
600
70
X10
• Argentina 2000: 400
– X5=89 años 200
– X10=79 años
65
0
1861 1875 1900 1925 195
1861 1900 1950 2000
Year
Year
1 | The postponement of mortality. Historical trends in X5 and
Vaupel JW. Biodemography Figure 2 | The emergence of the extremely old. T
of human ageing. Nature 2010;464:536-542
14. two strains of S. cerevisiae were used to yeast, death rates may
estimate mortality trajectories (Fig.0.01 Be-
0.1
3F). again.
0.05
cause the yeast were kept under conditions The trajectories in
Downloaded from www.sciencemag.org on August 11, 2011
10 120
Probabilidad de Morir 0.00
0 20 40 60 80 100 120 140
Age (days)
thought to preclude reproduction, death
rates were calculated from changes in the
size0of 20 40 60 80 100 120 140 0.001 they
0.0 the surviving cohort. Although
Age (days)
0
For instance, human
ages rises to heights t
gevity outliers found i
30
Age (days)
60
death Nematodes Yeast
Humans Automobiles
Medflies
s from 1.5 1.0 1.0
0.20
males. 1.0 E FA G B
gation
Probabilidad
rate Morir
nd 13 1.0
ntries) 0.15
period 0.1 1.0
de
s 80 to
Death rate
s 110 0.1
Death
0.10
serva-
2, but
0.01 0.5 0.01
ighest
mortal- 0.05
hough
assive
0.1
erson- 0.001 0.0 0.01 0.001 0.00
were 0 10 20 30 40 0 80 30 60 90
110 120
e who Age (days) EDAD
90 100
Age (days)
Age (years)
120 0 0 2 204 406 60 80 100 120 140
8 10 12 14
Age (years)
Age (days)
expo- Fig. 3. Age trajectories of death Nematodes
at best fits the data at ages 80 to 84 is shown in Death rates were Death rates from of a locally weighted procedure with a 1.
rates (48). (A) smoothed by use
• La probabilidad de morir desacelera luego de
at best fits the entire data set is shown in blue (16). window of 8122 for human Death rates, determined from survival data from
age 80 to days (52). (E) females. 1.0 E
he logarithm of death rate as a quadratic function populationline is for an for genetically homogeneous lines of nematode
The red samples, aggregation
at ages 105 and higher; it is shown in green. (B) worms, Caenorhabditis elegans, raised under experimental conditions
los 80 años. of 14 countries (Japan and 13
1,203,646 medflies, Ceratitis capitata (17 ). The similar to (53) but with density controlled (21). Age trajectories for the
Western European countries)
the blue curve for males. The prominent shoulder wild-type worm are shown as a solid red line (on a logarithmic scale given
with reliable data, over the period 0.1 1.
n arrow, is associated with the death of protein- to fromleft) and 1990 dashed red to (on an arithmetic scale given to the
the 1950 to as a for ages 80 line
h rate
Vaupel
JW,
et
al.
Science
1998;280:855-‐860
g to produce eggs (51). Until day 30, daily death right); the experimentfor ages 110 550,000 worms. Trajectories for the
109 and to 1997 included about
15. P robab i l i d a d de m orir, de s a c e l e ra
Probabilidad
anual
de
morir
por
rango
etario.
ArgenGna,
hombres,
2009,
2000,
y
1990
Elaboración
propia
en
base
a
WHO
1
0,9
0,8
2009
0,7
0,6
2000
0,5
1990
0,4
0,3
0,2
0,1
0
16. Expectativa a los 65
ExpectaGva
de
vida
a
los
65-‐69
años
de
edad,
ambos
sexos,
variación
porcentual,
tres
períodos
Elaboración
propia
en
base
a
WHO
122
120
Argen2na
118
116
Variación
porcentual
Brasil
114
Canadá
112
110
Japón
108
106
104
102
100
1990
2000
2009
17. Centenarios
Canadá
102
Canadá
103
Canadá
103
Japón
104
Japón
105
Japón
106
=Año
de
nacimiento
de
la
cohorte
• Cohortes y edad a la cual el 50% estará vivo
Christensen
K.
Ageing
popula2ons:
the
challenges
ahead
Lancet
2009;
374:
1196–1208
18. Longevidad y Salud
• ESPERANZA DE VIDA
FINAL
o L a e s p e r a n z a d e v i d a
aumenta por mayor
longevidad
19. Esperanza de vida y Senectud
ParGcipación
de
los
grupos
etarios
en
el
incremento
de
la
esperanza
de
vida
máxima
para
mujeres,
1850-‐2007
Elaboración
propia
en
base
a
Christensen
K
et
al,
Lancet
2009;374:1196-‐1208
100%
ParGcipación
en
la
ganancia
total
de
90%
>80
años
80%
esperanza
de
vida
70%
60%
65
a
79
50
a
64
50%
15
a
49
40%
30%
0
a
14
años
20%
10%
0%
1850-‐1900
1900-‐25
1925-‐50
1950-‐75
1975-‐90
1990-‐2007
20. Longevidad y Salud
• ENVEJECIMIENTO
o L o n g e v i d a d y m e n o r
fecundidad llevan al
envejecimiento poblacional
21. Edad Media, Evolución
Edad
Media
Popula2on
Division
of
the
Department
of
Economic
and
Social
Affairs
of
the
United
Na2ons
Secretariat,
World
Popula2on
Prospects:
The
2008
Revision,
hlp://esa.un.org/unpp
50,00
45,00
40,00
35,00
Argen2na
30,00
Bolivia
25,00
Brazil
20,00
Chile
15,00
Colombia
10,00
South
America
5,00
Europe
0,00
22. Fecundidad en descenso
ArgenGna
Tasa
de
Fecundidad
(hijos/mujer)
Elaboración
propia
en
base
a
INDEC
8
7
Hijos/vida
férGl
femenina
6
5
4
3
2
1
0
1869
1895
1914
1947
1960
1970
1980
1991
2001
23. Población Mayor: Argentina
55.000.000
50.000.000
45.000.000
40.000.000
35.000.000
Población
total
30.000.000
25.000.000
Población
65
años
y
20.000.000
más
15.000.000
10.000.000
5.000.000
15,6%
19%
10,5%
11,9%
13,6%
0
2010
2020
2030
2040
2050
Años
24. Longevidad y Salud
• POSTERGACIÓN DE LA
DISCAPACIDAD
o Compresión de la
morbilidad
25. Compresión de la Morbilidad
Enfermedad postergable Longevidad postergable
100
Sobrevivientes
80
Postergada
Sano
(%)
60
A
B
40
Precoz
Enf.
20
Edad
0
A
B
Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med 1980; 303:130-135
26. Envejecimiento, Riesgo, y
Discapacidad
• 1.741
alumni
Univ
Reevaluados
• Edad
≈43
años
• 77%
varones
Nivel
inicial
de
discapacidad
• Discapacidad
Anual
Health
Assesment
Ques.onaire
• Muerte
Nivel
inicial
de
Riesgo
• BMI
• Tabaquismo
• Ejercicio
1962
1986
1994
Vita
AJ,
Terry
RB,
Hubert
HB,
Fries
JF.
Aging,
health
risks,
and
cumula2ve
disability.
N
Engl
J
Med
1998;
338:1035-‐1041
27. 0.30
Disabilidad Acumulada
0.25
High risk
Disability Index
0.20
0.15
Moderate risk
0.10
Low risk
0.05
0.00
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78
Age (yr)
Figure 2. Disability Index According to Age at the Time of the Last Survey and Health Risk in 1986.
Average disability increased with age in all three risk groups, but the progression to a given level of
disability was postponed by approximately seven years in the low-risk group as compared with the
high-risk group. The horizontal line indicates a disability index of 0.1, which corresponds to minimal
disability.
Vita
AJ,
Terry
RB,
Hubert
HB,
Fries
JF.
Aging,
health
risks,
and
cumula2ve
disability.
N
engl
J
med
1998;
338:1035-‐1041
28. Envejecimiento, Riesgo, y
Discapacidad
• Hay predictores de discapacidad (riesgo)
– Tabaquismo
– Sedentarismo
– BMI
• A menor riesgo, la discapacidad se post-
pone
• A mayor discapacidad, peor progresión
Vita
AJ,
Terry
RB,
Hubert
HB,
Fries
JF.
Aging,
health
risks,
and
cumula2ve
disability.
N
engl
J
med
1998;
338:1035-‐1041
29. Evolución del paciente mayor
Probabilidad
de
cambio
de
estado
en
pac.
Mayores
Elaboración
propia
en
base
a
Lubitz
J
et
al,
2003
90
Probabilidad
(%)
de
cambiar
de
estado
80
70
60
el
año
siguiente
50
Sano
40
Ins2tucionalizado
30
Fallecido
20
10
0
Sano
75
Ins2tución
Sano
85
Ins2tución
75
85
Lubitz
J,
Cai
L,
Kramarow
E,
Lentzner
H.
Health,
life
expectancy,
and
health
care
spending
in
the
elderly.
N
Engl
J
Med
2003;
349:1048-‐55
30. Llegar a los 100
Enfermedad
42%
Sobrevivientes
<80
Enfermedad
45%
Retrasados
>80
No
13%
Escapados
Enfermedad
– No todos los centenarios contraen una
enfermedad crónica asociada a la edad en el
mismo momento de su vida.
Terry, D.F. et al. Cardiovascular advantages among the offspring of centenarians. J. Gerontol. A Biol. Sci.
Med. Sci. 2003; 58, M425–M431
31. Longevidad y Salud
• MEDICINA Y BIENESTAR
o L a l o n g e v i d a d s a l u d a b l e
depende de la medicina y
el bienestar general
32. Medicamentos y Longevidad
Efecto de los medicamentos sobre la longevidad
2,4
Longevidad ganada con medicación
Resto de longevidad ganada
Años de vida ganados
1,8
0,79
0,70
1,2
0,62
0,56
0,6
0,45
0,30
0,12
0,0
1988
1990
1992
1994
1996
1998
2000
33. Salud y Economía: Argentina
Variación
porcentual
de
PBI
y
Mortalidad
InfanGl,
1993=base
100
Elaboración
propia
sobre
datos
de
INDEC
180
Variación
porcentual
respecto
de
1993
160
140
120
100
80
60
40
PBI
20
Mortalidad
Infan2l
0
36. Cambio de Patología
Causas de Muerte por grupos! Traumaticas"
América Latina, WHO!
10000"
9000"
Muertes en .000s/año!
8000" Enfermedades no
comunicables"
7000"
6000"
5000"
4000" Enfermedades
3000" comunicables,
2000" condiciones
1000" maternas y
neonatales y
0" nutricionales"
2008" 2015" 2030"
37. Causas de Mortalidad, 2030
Figure 5. Projections of Global Deaths (Millions) for Selected Causes, for Three Scenarios: Baseline, Optim
doi: 10.1371/journal.pmed.0030442.g005
of demographic change are labelled ‘‘population growth’’ and highest and where HIV/A
‘‘population ageing’’ in Figure 7. The total projected change remain largely constant
38. Factores de Riesgo en la Arg e n ti a
Prevalencia
(%)
de
Detección
de
HTA,
DLP,
DBT
"Programa
de
Vigilancia
de
la
Salud
y
Control
de
Enfermedades"
VIGI+A
e
INDEC,
45,0
Encuesta
Nacional
de
Factores
de
Riesgo
2005.
40,0
Hipertensión
arterial
Hipercolesterolemia
Diabetes
35,0
30,0
25,0
20,0
15,0
10,0
5,0
0,0
39. Tabaquismo
Prevalencia
de
Tabaquismo
Elaboración
propia
según:
VIGI+A
e
INDEC,
ENFR
2005
Formosa
Santa
Fe
Misiones
Jujuy
Ciudad
de
Buenos
Aires
Chaco
Entre
Ríos
San2ago
del
Estero
Corrientes
Buenos
Aires
Total
del
país
Córdoba
Mendoza
San
Juan
Salta
Río
Negro
La
Rioja
Tucumán
Catamarca
San
Luís
Neuquén
Chubut
La
Pampa
Tierra
del
Fuego
Santa
Cruz
0
10
20
30
40
50
(%)
Mayores
de
18
años
que
fuman
actualmente
41. Costo y Salud
• AUMENTO INCESANTE
o El gasto en salud
tiende a aumentar
42. Gasto y Eficiencia
Gasto
en
Salud
y
Mortalidad<5
años;
100=año
2000
-‐Gasto
en
salud,
PPP-‐U$/capita,
total,
y
Mortalidad
en
<5
años-‐
WHO
170
Hungría
2008
Brasil
2008
Argen2na
2008
Gasto
en
salud/cápita
$-‐PPP
160
150
140
Chile
2008
130
120
110
Base,
año
2000
100
55
60
65
70
75
80
85
90
95
100
Mortalidad
en
<5
años
43. Gasto en salud
NO H AY N I N G U N A R A Z Ó N PA R A
DEFINIR ARBITRARIAMENTE UN
NIVEL DE GASTO EN SALUD.
SI E S O B L I G AT O R I O P R E T E N D E R
O B T E N E R M AY O R VA L O R P O R D I C H O
GASTO.
Fuchs
VR.
Health
care
expenditure
reexamined.
Ann
Intern
Med
2005;
143:
76-‐8
44. Gasto en Salud
• Efectos del Aumento del Gasto en Salud
– Sobre las cuentas públicas
• Quita
fondos
a
otras
áreas
– Sobre la economía real
• Aumenta
los
costos
de
bolsillo
en
un
área
que
altera
la
dinámica
económica
– No
sigue
leyes
de
mercado
» Asimetría
de
información
» Es
imprescindible
» El
decisor
(médico)
incen2vado
por
un
sector
más
que
otro
– Afecta
a
trabajador
y
empleador
Orszag PR. How health care can save or sink America. Foreign Affairs 2011; July/August
Fuchs VR. Health care expenditure reexamined. Ann Intern Med 2005; 143: 76-8
45. Costo y Salud
• HAY SUBTRATAMIENTO
o E l s u b t r a t a m i e n t o s e a s o c i a a
un costo de oportunidad
desaprovechado
46. Calidad de Atención en Adultos
The Health Insurance Experiment
A Classic RAND Study Speaks to the Current
Health Care Reform Debateondiciones
30
C
seleccionadas
agudas
PARA CADA CONDICIÓN:
A
RAND RESEARCH AREAS
fter decades of evolution and crónicas
y
• 6.712
personas
Key findings: • Medición de tratamiento
THE ARTS
CHILD POLICY experiment, the U.S. health care
• Adultos
CIVIL JUSTICE
EDUCATION
system has yet to solve a funda-
recibido
• In a large-scale, multiyear experiment,
mental challenge: delivering quality
• 439
ordable • Comparación con tratamiento
12
ciudades
USA
Americans at an affindicadores
de
care used fewer health services
ENERGY AND ENVIRONMENT
participants who paid for a share of their
HEALTH AND HEALTH CARE health care to all
health
• Contacto
explored and older ideas revisited. One de
atención
comparison group given free care.
tel.
calidad
price. In the coming years, new solutions will
recomendado
INTERNATIONAL AFFAIRS
NATIONAL SECURITY than a
be
Acceso
a
that has returned to prominence is cost
POPULATION AND AGING
• PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
idea • Cost sharing reduced the use of both
Historias
clínicas
care expense and responsibil-
SUBSTANCE ABUSE
TERRORISM AND
sharing, which involves shifting a greater
share of health
highly effective and less effective services
in roughly equal proportions. Cost sharing
HOMELAND SECURITY
ity onto consumers. Recent public discussion did not significantly affect the quality of
TRANSPORTATION AND
INFRASTRUCTURE
WORKFORCE AND WORKPLACE
Tratamientos
y
of cost sharing has often cited a landmark care received by participants.
medidas
preven2vas
RAND study: the Health Insurance Experi-
1998
• Cost sharing in general had no adverse 2000
ment (HIE). Although it was completed over
effects on participant health, but there
two decades ago, in 1982, the HIE remains
were exceptions: free care led to improve-
the only long-term, experimental study of cost
ments in hypertension, dental health,
sharing and its effect on service use, quality of
vision, and selected serious symptoms. These
care, and health. e purpose of this research
McGlynn
EA,
Asch
SM,
Adams
main eesey
J,
Hicks
Jsickest andwere concentratedKerr
EA.
The
Quality
of
Health
brief is to summarize the HIE’s J,
K findings
improvements
the
,
DeCristofaro
A,
among
poorest patients.
Care
Delivered
to
Adults
for today’sUnited
States.
N
Engl
J
Med
2003;348:2635-‐45.
and clarify its relevance in
the
debate.
Our goal is not to conclude that cost sharing is
47. Calidad de Atención
Proporción
del
tratamiento
teóricamente
recomendado,
efecGvamente
recibido
por
los
pacientes.
EE.UU.,
12
áreas
metropolitanas,
2003
The Healthpropia
s/RAND,
The
First
Na2onal
Report
Card
on
Quality
of
Health
Care
in
America
Elab
Insurance Experiment
100%
A Classic RAND Study Speaks to the Current
Health Care Reform Debate
90%
A
RAND RESEARCH AREAS
fter decades of evolution and
80%
45,1
45,1
Key findings: 43,9
46,5
THE ARTS
CHILD POLICY experiment, the U.S. health care
system has yet to solve a funda-
70%
CIVIL JUSTICE
EDUCATION • In a large-scale, multiyear experiment,
ENERGY AND ENVIRONMENT
mental challenge: delivering quality
participants who paid for a share of their
health care to all Americans at an affordable
60%
HEALTH AND HEALTH CARE
INTERNATIONAL AFFAIRS
price. In the coming years, new solutions will
health care used fewer health services
NATIONAL SECURITY than a comparison group given free care.
be explored and older ideas revisited. One
50%
POPULATION AND AGING
idea that has returned to prominence is cost
No
recibido
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
• Cost sharing reduced the use of both
sharing, which involves shifting a greater
40%
SUBSTANCE ABUSE
TERRORISM AND share of health care expense and responsibil-
highly effective and less effective services
in roughly equal proportions. Cost sharing
HOMELAND SECURITY
30%
TRANSPORTATION AND
INFRASTRUCTURE
WORKFORCE AND WORKPLACE
Recibido
ity onto consumers. Recent public discussion
of cost sharing has often cited a landmark
did not significantly affect the quality of
care received by participants.
RAND study: the Health Insurance Experi-
20%
ment (HIE). Although it was completed over • Cost sharing in general had no adverse
effects on participant health, but there
two decades ago, in 1982, the HIE remains
10%
the only long-term, experimental study of cost
were exceptions: free care led to improve-
ments in hypertension, dental health,
sharing and its effect on service use, quality of
0%
care, and health. e purpose of this research
vision, and selected serious symptoms. These
improvements were concentrated among
General
Prevención
brief is to summarize the HIE’s main findings Agudo
the sickest and poorest patients. Crónico
and clarify its relevance for today’s debate.
Tipo
de
tratamiento
Our goal is not to conclude that cost sharing is
good or bad but to illuminate its effects so that
48. Calidad de Atención
Proporción
del
tratamiento
teóricamente
recomendado,
efecGvamente
recibido
por
los
pacientes.
EE.UU.,
12
áreas
metropolitanas,
2003
The Healthpropia
s/RAND,
The
First
Na2onal
Report
Card
on
Quality
of
Health
Care
in
America
Elab
Insurance Experiment
100%
A Classic RAND Study Speaks to the Current
Health Care Reform Debate
90%
A
80%
35
41
42
42
fter decades of evolution and
45
RAND RESEARCH AREAS
THE ARTS
experiment, the U.S. health care Key findings: 50
55
55
70%
CHILD POLICY
CIVIL JUSTICE
system has yet to solve a funda- 60
• In a large-scale, multiyear experiment,
60%
EDUCATION
ENERGY AND ENVIRONMENT
mental challenge: delivering quality
participants who paid for a share of their
HEALTH AND HEALTH CARE health care to all Americans at an affordable
health care used fewer health services 90
50%
INTERNATIONAL AFFAIRS
NATIONAL SECURITY
price. In the coming years, new solutions will
than a comparison group given free care.
be explored and older ideas revisited. One
40%
POPULATION AND AGING
PUBLIC SAFETY
idea that has returned to prominence is cost • Cost sharing reduced the use of both
SCIENCE AND TECHNOLOGY
30%
SUBSTANCE ABUSE
No
recivido
sharing, which involves shifting a greater highly effective and less effective services
TERRORISM AND share of health care expense and responsibil- in roughly equal proportions. Cost sharing
20%
Recivido
HOMELAND SECURITY
TRANSPORTATION AND ity onto consumers. Recent public discussion did not significantly affect the quality of
INFRASTRUCTURE
of cost sharing has often cited a landmark care received by participants.
10%
WORKFORCE AND WORKPLACE
RAND study: the Health Insurance Experi-
ment (HIE). Although it was completed over • Cost sharing in general had no adverse
0%
two decades ago, in 1982, the HIE remains effects on participant health, but there
were exceptions: free care led to improve-
the only long-term, experimental study of cost
ments in hypertension, dental health,
sharing and its effect on service use, quality of
vision, and selected serious symptoms. These
care, and health. e purpose of this research improvements were concentrated among
brief is to summarize the HIE’s main findings the sickest and poorest patients.
and clarify its relevance for today’s debate.
Our goal is not to conclude that cost sharing is
good or bad but to illuminate its effects so that
49. Mamografía
Mamograha
en
los
úlGmos
dos
años
según
provincia.
Localidades
de
5.000
y
más
habitantes.
Total
del
país.
Noviembre
de
2009.
Se
toma
como
población
de
referencia
a
mujeres
de
40
años
y
más
que
se
realizaron
por
lo
menos
una
mamograxa
en
los
úl2mos
2
añ
100%
90%
80%
70%
60%
50%
40%
30%
Mamograxa
No
20%
Mamograxa
Sí
10%
0%
51. Costo y Salud
• DETERMINANTES
o E l g a s t o e n s a l u d c a m b i a
con la demografía
52. Contribución relativa de diferentes
servicios de salud al crecimiento total del
gasto, USA 1996-2017
Otros
17.8%
Hospitales
Other
Personal
28.6%
Health
Care
12.1%
Home
Health
Médicos
Care
21.0%
1.8%
Medicamentos
Nursing
Home
14.3%
Care
4.4%
Notes:
Percentages
may
not
total
100%
due
to
rounding.
Other
Personal
Health
Care
includes,
for
example,
dental
and
other
professional
health
services,
durable
medical
equipment,
etc.
Other
Health
Spending
includes,
for
example,
administra2on
and
net
cost
of
private
health
insurance,
public
health
ac2vity,
research,
and
structures
and
equipment,
etc.
Source:
Kaiser
Family
Founda2on
calcula2ons
using
NHE
data
from
Centers
for
Medicare
and
Medicaid
Services,
Office
of
the
Actuary,
Na2onal
Health
Sta2s2cs
Group,
at
hlp://www.cms.hhs.gov/Na2onalHealthExpendData/
(see
Historical;
Na2onal
Health
Expenditures
by
type
of
service
and
source
of
funds,
CY
1960-‐2006;
file
nhe2006.zip).
53. Causas de Gasto Total
Gasto
Total,
10
primeras
causas,
Adultos,
US
2008
Center
for
Financing,
Access,
and
Cost
Trends,
AHRQ,
Household
Component
of
50
the
Medical
Expenditure
Panel
Survey,
2008
109 U$S
40
Mujeres
Hombres
30
20
10
0
54. GASTO R E L AT I V O E N S A L U D Y E D A D
Gasto relativo per cápita en salud, por grupo etario,
EE.UU 1999
Edad 35-44 años=1
Gasto relativo Meara E, White C, Cutler DM, 2003
6
5
4
3
2
1
0
0-‐5
6-‐14
15-‐24
25-‐34
35-‐44
45-‐54
55-‐64
65-‐74
75+
55. Causas de la demanda
Modificación
de
la
acGvidad
anual,
según
drivers
demográfico
y
otros
Elaboración
propia
en
base
a
Dash
P,
Llewellyn
C,
Richardson
B.
Developing
a
regional
health
system
strategy.
McKinsey
Quarterly
2011
6
Otros
Variación
anual
(%)
5
Demografía
4
3
2
1
0
56. Causas de Gasto, >65 años
Gasto
Total,
Primeras
causas,
Mayores,
US
2008
Center
for
Financing,
Access,
and
Cost
Trends,
AHRQ,
Household
Component
109 U$S of
the
Medical
Expenditure
Panel
Survey,
2008
50
40
30
20
10
0
Enf.
Cardíaca
Cáncer
Osteoartri2s
Hipertensión
Trauma
Asoc
57. Gasto en Medicamentos
Drogas
más
prescriptas,
Ambulatorio,
Adultos,
US
2008
Center
for
Financing,
Access,
and
Cost
Trends,
AHRQ,
Household
and
Pharmacy
Components
of
the
Medical
Expenditure
Panel
Survey,
2008
(%)
del
total
prescripto
ambulatorio
25 Gasto
Ambulatorio
22,5
20
Top
5
15 33%
15,1
10 12,3
8,7
8,4
5
0
DBT y DLP Analgésicos, Cardiovascular Gastrointestinal Psicotrópicos
Anticonvulsivos,
Antiparkinson
58. Drogas más vendidas
Clases
terapéuGcas
de
mayor
facturación,
mundo,
proyección
2015
Elaboración
propia
en
base
a:
IMS.
The
Global
Use
of
Medicines:
Outlook
Through
2015.
Report
by
the
IMS
Ins2tute
for
Healthcare
Informa2cs
Glaucoma
Antivirales
Alzheimer
Proporción del mercado
Eritropoyesis
global, 2015=U$S1012!
ADHD
Analgésicos
Osteoporosis
Esclerosis Múltiple
Anti-epilépticos
Antidepresivos
Anti-ulcerosos
Antiagregantes
41%
Antipsicóticos
Anti HIV
Resto
Autoinmunes
Angiotensina
Colesterol
Respiratorias
Diabetes
Oncología
0
20
40
60
80
100
U$S
miles
de
millones
59. Top Ten año 2014
FARMA
USO
DROGA
LAB
U$S
X109
Avasta2n
Cáncer
Bevacizumab
Roche
8,9
Humira
Artri2s
Adalimumab
Abol
8,5
Enbrel
Artri2s
Etanercept
Pfizer
8
Crestor
Colesterol
Rozuvasta2na
AstraZeneca
7,7
Remicade
Artri2s
Infliximab
Merck
7,6
Rituxan
Cáncer
Rituximab
Roche
7,4
Lantus
Diabetes
Insulina
Glargina
Sanofi-‐Aven2s
7,1
Advair
Asma/EPOC
Flu2casona-‐Sameterol
GSK
6,8
Hercep2n
Cáncer
Trastuzumab
Roche
6,4
Novolog
Diabetes
Insulina-‐Aspartato
Novo
Nordisk
5,7
TOTAL
74,1
Total
Global
Drug
Sales
1.000
(*)
FACTBOX-‐World's
top-‐selling
drugs
in
2014
vs
2010.
Thomson-‐Reuters
(*)
Global
drug
sales
to
top
$1
trillion
in
2014:
IMS.
Thomson
Reuters
60. Concentración
del
gasto
en
salud,
USA
2005
100%
96,5%
Porcentaje
del
gasto
total
en
salud
80,6%
80%
74,4%
65,5%
60%
50,2%
40%
22,7%
20%
3,5%
0%
Top
1%
Top
5%
Top
10%
Top
15%
Top
20%
Top
50%
Bolom
50%
Porcentaje
de
la
población
rankeada
según
nivel
de
gasto
Note:
Dollar
amounts
in
parentheses
are
the
annual
expenses
per
person
in
each
percen2le.
Popula2on
is
the
civilian
nonins2tu2onalized
popula2on,
including
those
without
any
health
care
spending.
Health
care
spending
is
total
payments
from
all
sources
(including
direct
payments
from
individuals,
private
insurance,
Medicare,
Medicaid,
and
miscellaneous
other
sources)
to
hospitals,
physicians,
other
providers
(including
dental
care),
and
pharmacies;
health
insurance
premiums
are
not
included.
Source:
Kaiser
Family
Founda2on
calcula2ons
using
data
from
U.S.
Department
of
Health
and
Human
Services,
Agency
for
Healthcare
Research
and
Quality,
Medical
Expenditure
Panel
Survey
(MEPS),
2005.
61. Concentración del Gasto
ParGcipación
en
el
Gasto
en
Salud,
según
canGdad
de
población.
US,
población,
2005-‐2006;
MEPS
(Cohen,
Rohde,
2009)
Porcentaje
de
la
población
según
nivel
de
gasto
(percenGlo)
0 Top 1% Top 5% Top 10% Top 25% Top 50% 100
100
Porcentaje
del
Gasto
Total
en
Salud
90
80
81,9
70
95,7
60
59,5 81,9
50
44 59,5
40
44
30
18,7
20
18,7
10
Top 1% Top 5% Top 10% Top 25% Top 50%
0
62. Predictores de Riesgo
ParGcipación
en
el
Gasto
en
Salud,
según
Edad.
US,
población,
2005-‐2006;
MEPS
(Cohen,
Rohde,
2009)
Porcentaje
de
población
según
grupo
etario
100%
90%
13,2
80%
26,8
25,3
70%
35,1
60%
45,1
65
y
más
50%
45-‐64
40%
30-‐44
36,6
30%
18-‐29
20%
0-‐17
10%
0%
Población Top 5% Top 6-10% Top 11-25%
General P e r c e n G l o
d e
G a s t o
63. Costo y Salud
• GASTO O INVERSIÓN
o El gasto en salud posee
réditos sociales
64. Gasto en Salud y Mortalidad
Simulación: gasto en salud y mortalidad infantil
Elaboración propia, en base a INDEC y Censo 2001
Mortalidad Infantil (<1año/1.000 nv)
20,5
20
19,5
19
18,5
18
17,5
17
16,5
16
15,5
7
8
9
10
Gasto en Salud (% del PBI)
Aumentar el gasto en salud 1% del PBI, baja la mortalidad
infantil 0,6%
IMF
Working
Paper.
Fiscal
Affairs
Department.
Social
Spending,
Human
Capital,
and
Growth
in
Developing
Countries:Implica2ons
for
Achieving
the
MDGs.
By
Emanuele
Baldacci,
Benedict
Clements,
Sanjeev
Gupta,
and
Qiang
Cui.
November
2004
65. Gasto en Salud y Riqueza !
GDP
PER
CAPITA
Y
GASTO
PER
CAPITA
EN
SALUD,
OECD
2007
8000
EE.UU.
Gasto
en
Salud/año/cápita,
$PPP
7000
6000
5000
4000
Luxemburgo
3000
2000
R²
=
0,56879
1000
OECD
Economic
Data
2009,
OECD
0
0
20000
40000
60000
80000
100000
PBI
per
cápita,
$PPP
66. Costo y Salud
• E N LÍNE A CO N DI NÁ MI C A
SOC IO-DE MO G RÁF I CA
o E l g a s t o s e c o n c e n t r a e n
lo más frecuente: añosos
y cardiovascular
67. Relación crítica
Salud
Longevidad
Gasto
Lubitz
J,
Cai
L,
Kramarow
E,
Lentzner
H.
Health,
life
expectancy,
and
health
care
spending
in
the
elderly.
N
Engl
J
Med
2003;
349:1048-‐55
68. H e a l t h , L i f e E x p e c t a n c y, a n d H e a l t h
Care Spending among the Elderly
Nagi
score
Limitaciones:
IADL
• Nagi +1
1992
–
1998:
3/año:
• IADL+1
Medicare
Current
ADL
beneficiary
Survey
• ADL+1
Ins2tucionalizado
• Instit.+
• Muerto+
Muerto
N=16.964,
Medicare
>69 años
Lubitz
J,
Cai
L,
Kramarow
E,
Lentzner
H.
Health,
life
expectancy,
and
health
care
spending
in
the
elderly.
N
Engl
J
Med
2003;
349:1048-‐55