Marcos Bosi Ferraz"
H ealth eco n o m ics:
th e illu sio n an d th e "b lad d er effect"
I
o f th e m , e m p h a s isa lm o s tn a ll c o u n trie sis p la c e do f th e w o rld n o w a d a y s ,o n th e im b a la n c e b e tw e e nif n o t a llth e m in im u m n e e d s o f s o c ie ty a n d th e re s o u rc e s
a v a ila b le to a tte n d to th e m . T h e h e a lth s e c to r p ro v id e s a n
e x a m p le in w h ic h th e q u e s t fo r s e rv ic e a t w h a t is c o n s id e re d
a n e s s e n tia l m in im u m le v e I h a s g e n e ra te d m a n y d iffic u ltie s
a t th e le v e I o f s o c ie ty a s a w h o le .
H e a lth e c o n o m ic s , a n e w fie ld (a t le a s t in B ra z il)
w h ic h in v o lv e s m e d ic a I c o n c e p ts a n d k n o w le d g e ju s t a s
m u c h a s e c o n o m ic p rin c ip Ie s , h a s th e p o te n tia I to c o n trib u te
to th e c la rific a tio n o f d o u b ts in re la tio n to th e u tiliz a tio n o f
re s o u rc e s in th e Iig h t o f th e n e e d s o f s o c ie ty . T h e b a s ic
p rin c ip Ie o f h e a Ith e c o n o m ic s is n o t to e c o n o m iz e o n th e
re s o u rc e s a v a iIa b Ie , b u t ra th e r to m a k e u s e o f th e m in th e
b e s t w a y p o s s ib Ie . H e a Ith e c o n o m ic s d o e s n o t a im to d e fin e
w h a t a ttitu d e s o r d e c is io n s s h o u Id b e ta k e n , b u t ra th e r to
s u p p ly d a ta o r in fo rm a tio n s o th a t th e s e d e c is io n s , a t th e
le v e I o fh e a lth c a re , a re m a d e in a w a y th a t ta k e s in to a c c o u n t
th e c o n te x t s u rro u n d in g th e d e c is io n s .
H e a Ith e c o n o m ic s h a s th re e b a s ic c o n c e p ts : s c a rc ity ,
c h o ic e , a n d o p p o rtu n ity c o s t. T h e firs t o f th e s e , a lre a d y
to u c h e d o n in th e in tro d u c tio n , re fe rs to th e fa c t th a t
*Prof. Adjunto do Depto. de Medicina, Disciplina de
Reumatologia
- UNIFESP
re s o u rc e s a re a n d w ill a lw a y s b e s c a rc e fo r a tte n d in g to th e
n e e d s th a t s o c ie ty c o n s id e rs to b e th e ln in im u m d e s ire d . In
p a rt, th is is d u e to c o n s ta n t te c h n o lo g ic a l a d v a n c e a n d th e
in c re a s in g d e m a n d s o f s o c ie ty its e lf a s it e v o lv e s .
C o n s e q u e n tly , th e te n d e n c y is to d e m a n d m o re a s e a c h d a y
p a s s e s . T h e c e llu la r te le p h o n e , fo r e x a m p le , o n ly a d re a m
s o m e y e a rs a g o , is to d a y a re a lity w h ic h is b e c o m in g m o re
a n d m o re in d is p e n s a b le .
T h e s e c o n d c o n c e p t, c h o ic e , c o m e s fro m th e g re a t
n u m b e r o f o p tio n s a v a ila b Ie a n d th e lim ite d a n d fin ite n a tu re
o f p u rç h a s in g p o w e r, o r in o th e r w o rd s , re s o u rc e s a re a n d
w ill a lw a y s b e lim ite d . In o u r d a ily liv e s , w e e x e rc is e c h o ic e
lik e th is in th e fa c e o f th e in n u m e ra b le o p tio n s w h ic h e x is to
O p p o rtu n ity c o s t is th e b a s is fo r ju s tify in g th e p ro c e s s o f
c h o ic e . If re s o u rc e s a re fin ite , th e a c q u is itio n o f o n e p ro d u c t
o r s e rv ic e c o u Id m a k e it im p ra c tic a b le to a c q u ire a n o th e r
p ro d u c t 9 r s e rv ic e . W e p u t o p p o rtu n ity c o s t in to p ra c tic e
e v e ry d a y . W h e n w e g o to a s u p e rm a rk e t a n d c h o o s e
b e tw e e n tw o p ro d u c ts , u s u a lly o n e m o re e x p e n s iv e a n d o f
b e tte r q u a lity a n d th e o th e r c h e a p e r a n d o f lo w e r q u a lity ,
w e a re c o n s c io u s ly e v a lu a tin g w h e th e r th e q u a lity 'is w o rth
th e a d d itio n a I c o s t. If it w a s n o t fo r th e lim ita tio n o n
re s o u rc e s , th is c h o ic e (th e o p p o rtu n ity c o s t o f a c q u irin g th e
p ro d u c t o f b e tte r q u a lity ) w o u ld h a v e n o m e a n in g , a s w e
w o u ld a lw a y s b u y th e o n e w h ic h w a s d e m o n s tra b ly o fb e tte r
q u a Iity .
In m e d ic in e , th e s e c o n c e p ts a re a ls o p u t in to p ra c tic e
e v e ry d a y a n d b y a ll o f u s o W e o n ly h a v e to th in k a little !
1 5 3 0
T h e b ig p r o ~ le m is th a t, a s c o n s u m e r s , w e m a k e th e
d e c is io n s , d e c id in g w h e th e r o r n o t it is w o r th g e ttin g th e
b e s t p r o d u c t in te r m s o f q u a lity , a t th e c o s t o f u s in g u p
m o r e o f o u r r e s o u r c e s . A s p a tie n ts , h o w e v e r , th is d e c is io n
o f te n d o e s n o t d e p e n d o n ly o n o u r w ill. I n m o s t c a s e s , th e
p a tie n t d e le g a te s th e d e c is io n s o f c h o ic e a n d o p p o r tu n ity
c o s t to th e h e a lth p r o f e s s io n a l. T h is h e a lth p r o f e s s io n a l is
th e " a g e n t" o f th e p a tie n t. C o n s e q u e n tly , th e h e a lth
p r o f e s s io n a l h a s th e p o w e r to g e n e r a te th is d e m a n d a n d
th u s , in a w a y ,- a lte r th e w h o le p r o c e s s o T h is is a v e r y
im p o r ta n t c h a r a c te r is tic o f h e a lth e c o n o m ic s w h ic h , w ith o u t
d o u b t, s h o u ld b e g iv e n s p e c ia l a tte n tio n b y s o c ie ty a s a
w h o le . H e r e a r e s o m e s c e n a r io s in v o lv in g th e p a r tic ip a tio n
o f d if f e r e n t c h a r a c te r s in th e d e c is io n - m a k in g p r o c e s s , in
te r m s o f h o w b e s t to u tiliz e th e r e s o u r c e s a v a ila b le , w h ic h
s e r v e to ilI u s tr a te th is c h a r a c te r is tic a n d d e s e r v e s o m e
r e f le c tio n :
1 . S c e n a r i o A : I I H e a l t h p r o m o t i o n i n t h e p u b l i c s e c t o r "
I n a lm o s t a lI B r a z il, if n o t a lI , w e h a v e e n o r m o u s
q u e u e s o f p a tie n ts in p u b lic c a s u a lty s e r v ic e s w a itin g f o r
m e d ic a I a tte n tio n ( o f te n , if n o t th e m a jo r ity , b e in g o u tp a tie n t
c a s e s ) , w h e r e a r e d u c e d n u m b e r o f d o c to r s a r e a c tu a lI y o n
d u ty , d is c o n te n te d b e c a u s e o f th e w o r k in g c o n d itio n s in
w h ic h th e y a r e e x e r c is in g th e ir p r o f e s s io n , a n d b e c a u s e o f
th e ir d is g r a c e f u l s a la r ie s . I s th is s c e n a r io a n illu s io n ?
2 .S c e n a r i o B : I I H e a l t h p r o m o t i o n i n t h e h e a l t h i n s u r a n c e a n d g r o u p m e d i c i n e s e c t o r s "
I n a lm o s t a lI B r a z il, if n o t a ll, th e r e a r e b o o k le ts lis tin g
d o c to r s , h o s p ita I s a n d o th e r h e a lth p r o f e s s io n a ls r e g is te r e d
o r a u th o r iz e d to p r o v id e s e r v ic e s to a s e le c t g r o u p o f u s e r s .
I n th is c a s e to o , m a n y o f th e s e r v ic e s r e n d e r e d a r e f r e q u e n tly
r e im b u r s e d a t d is g r a c e f u l r a te s . I s th is s c e n a r io a n illu s io n ?
3 . S c e n a r i o C : I I H e a l t h p r o m o t i o n d e p e n d e n t o n t h e d e c i s i o n
o f t h e p r o f e s s i o n a l " .
I n th is s c e n a r io , a s a n e x a m p le , le t u s c o n s id e r a
d e r m a to lo g is t w h o s e e s a p a tie n t ( p r iv a te , p u b lic o r in s u r e d )
in h is c o n s u lta tio n o f f ic e a n d a f te r d ia g n o s tic a s s e s s m e n t is
f a c e d w ith th e s itu a tio n o f a d e f in e d d is e a s e w h ic h h a s tw o
p o s s ib ilitie s f o r tr e a tm e n t: p o s s ib ility A , w ith 9 0 %
p o s s ib ility o f a c u r e f o r th e d is e a s e a t a c o s t o f X , a n d
p o s s ib ility B , w ith a 9 5 % p o s s ib ility o f a c u r e f o r th e d is e a s e
a t a h y p o th e tic a l c o s t o f 1 0 0 tim e s X . T h e p r o f e s s io n a l h a s
a r e s p o n s ib ility to h is p a tie n t a n d to s o c ie ty . W h a t d e c is io n
s h o u ld b e m a d e r e g a r d in g tr e a tm e n t?
F E R R A Z , M . S . - H e a lt h e c o n o m ic s : t h e iI I u s io n a n d t h e " b la d d e r e f f e c t "
4 . S c e n a r i o D : I I H e a l t h p r o m o t i o n i n v o l v i n g p r o d u c t s o f h e a l t h - r e l a t e d i n d u s t r i e s "
I n th is s c e n a r io , le t u s im a g in e a n o r th o p e d is t w h o
s e e s a p a tie n t ( p r iv a te , p u b lic o r in s u r e d ) in h is c o n s u lta tio n
o f f ic e a n d a f te r d ia g n o s tic a s s e s s m e n t is f a c e d w ith th e
f o llo w in g s itu a tio n : th e r e is a d e f in e d d is e a s e w h ic h
n e c e s s ita te s a p r o s th e s is . T h e r e a r e tw o o f th e m o n th e
m a r k e t, o n e w ith a n " a v e r a g e lif e s p a n " o f 8 y ~ a r s w h ic h
c o s ts X a n d th e o th e r w ith a n " a v e r a g e lif e s p a n " o f 1 2 y e a r s
w h ic h c o s ts tw ic e X . T h e p r o f e s s io n a l h a s a r e s p o n s ib ility
to h is p a tie n t a n d to s o c ie ty . W h a t d e c is io n s h o u ld b e m a d e
r e g a r d in g th e c h o ic e o f p r o s th e s is ?
I n a lI th e a b o v e s c e n a r io s , th e r e is s c a r c ity o f
r e s o u r c e s , c h o ic e , a n d o p p o r tu n ity c o s t. F u r th e r m o r e , th e r e
is th e f ig u r e o f th e h e a lth p r o f e s s io n a l a s th e " a g e n t" o f th e
p a tie n t ( o r in o th e r w o r d s , th e p r o f e s s io n a l w h o w ilI m a k e
th e d e c is io n f o r th e p a tie n t c o n c e r n in g th e c h o ic e a n d
o p p o r tu n ity c o s t, u s in g th e s c a r c e r e s o u r c e s o f th e p a tie n t
o r o f s o c ie ty a s a w h o le ) . I n e a c h s c e n a r io , h o w e v e r , th e
d y n a m ic s o f th e d e c is io n to b e m a d e a r e p a r tic u la r a n d th e .
r e s u lts w h ic h s te m f r o m th is d e c is io n a r e d is tin c t.
I n S c e n a r io A , w h a t h a p p e n s is th a t in p a y in g th e
h e a lth p r o f e s s io n a l in th is d is g r a c e f u l w a y , a n illu s io n th a t
th is h e a lth s e c to r c a n m a k e s a v in g s is c r e a te d . T h e s e s a la r ie s
a r e v e r y w e lI - e n u m e r a te d a n d d o c u m e n te d a m o n g s t u s o I t
is f o r g o tte n , h o w e v e r ( p e r h a p s f o r c o n v e n ie n c e ) , th a t th e s e
d o c to r s a r e u s in g th e o th e r e x is tin g r e s o u r c e s e x c e s s iv e ly ,
p r e c is e ly b e c a u s e th e y d o n o t h a v e a c c e p ta b le m in im u m
w o r k in g c o n d itio n s . A p r a c tic a l e x a m p le o f th is is th e
e x c e s s iv e n u m b e r o f x - r a y e x a m in a tio n s c a r r ie d o u t in
c a s u a lty s e r v ic e s to d o c u m e n t in f e c tio n s o f th e u p p e r
r e s p ir a to r y tr a c t, ie c o m m o n c o ld s . ( S o m e tim e s th e x - r a y
is d e m a n d e d b y p a tie n ts th e m s e lv e s , a n d a t o th e r tim e s it is
s im p ly a r e f le c tio n o f n o t g e ttin g th e c lin ic a I h is to r y , a n
in c o m p le te c lin ic a I e x a m in a tio n , a n d c o n s e q u e n t n o n
-e s ta b lis h m -e n t o f a n a p p r o p r ia te d o c to r - p a tie n t r e la tio n s h ip
o r g e n e r a tio n o f c o n f id e n c e ) . M o r e o v e r , it is n o te w o r th y
th a t th e x - r a y te c h n ic ia n s o m e tim e s r e p e a ts th e s a m e x - r a y
f o u r o r f iv e tim e s to r e a c h a n a c c e p ta b le q u a lity , e ith e r
b e c a u s e th e e q u ir m e n t is in a d e q u a te o r b e c a u s e h e d o e s
n o t h a v e s u f f ic ie n t tr a in in g . T h e s e e x a m p le s a r e h a p p e n in g
n o w a n d a lI th e tim e in th is c o u n tr y o f o u r s . T h e r e is n o
s h o r ta g e o f o th e r s im ila r e x a m p le s .
W h a t k in d o f illu s o r y e c o n o m ic s is th is ? W h o is p a y in g
th is b ill? I t is a ll o f u s ! T h is is a n e x a m p le o f th e s o - c a lle d
" b la d d e r e f f e c t" , in w h ic h o n e s id e is s q u e e z e d a n d o n th e
o th e r s id e th e r e is a n e x c e s s iv e ly in c r e a s e d u s e o f r e s o u r c e s .
I s th e r e s o m e o n e in th e p u b lic s e c to r to d a y w h o is c o n c e m e d
w ith d o c u m e n tin g th is p r o b le m ? C o u ld th is 'o e th e m o m e n t
to c o n c e r n o u r s e lv e s m o r e w ith g e ttin g to k n o w a ll f a c e ts
o f th e p r o b le m a n d h a v in g a t le a s t th e c u r io s ity , w ith th e
1531
p a rtic ip a tio n o f th o se d ire c tly in v o lv e d , to se a rc h fo r
so lu tio n s w h ic h p ro v id e a re tu m fo r so c ie ty a n d n o t ju st
p o litic a l d e c isio n s fo r o u r o w n u se a n d b e n e fit? In th is
e x a m p le , th e p o w e r a s " a g e n t" o f th e d o c to r o r h e a lth
p ro fe ssio n a l is illu stra te d . T h e se p e o p le sh o u ld b e tre a te d
w ith re sp e c t a n d d ig n ity , a s th e y d e fin e h o w m u c h a n d in
w h a t w a y to b e tte r u tiliz e p u b lic re so u rc e s. T h is is c e rta in ly
n o t h a p p e n in g ! T h e illu sio n is to p a y th e p ro fe ssio n a l b a d ly
a n d e c o n o m iz e in th e p u b lic se rv ic e .
In sc e n a rio B , th e h e a lth p ro fe ssio n a l h a s th e
re sp o n sib ility to p ro v id e c o n su lta tio n s to p a tie n ts, u su a lly
in h is o w n o ffic e . T h e g e n e ra tio n o f d e m a n d b y th e d o c to r
c a n b e se e n h e re a s w e ll. F re q u e n tly , th e p ro fe ssio n a l is
re im b u rse d fo r h is se rv ic e s in a n e q u a lly d isg ra c e fu l w a y , ,
a lth o u g h , fa c e d w ith th e n e c e ssitie s o f d a ily life a n d in th e
h o p e o f o n e d a y g e ttin g th a t p ri v a te p a tie n t, th e se
p ro fe ssio n a ls a c c e p t th e e sta b lish e d ro le s. In th is e x a m p le
o n c e a g a in , c o n su lta tio n s o f sh o rt d u ra tio n h a v e b e c o m e
fre q u e n t, to m a k e th e " b u sin e ss" e c o n o m ic a lly v ia b le . A s
a fu rth e r c o n se q u e n c e , in u m e ra b le re q u e sts fo r
su p p le m e n ta ry e x a m in a tio n s a re m a d e a n d re tu rn
c o n su lta tio n s a re a rra n g e d . A g a in th e re is th e illu sio n o f
e c o n o m iz in g : b y p a y in g th e p ro fe ssio n a l in a d e q u a te ly , h e
g e n e ra te s a d e m a n d fo r o th e r re so u rc e s, o fte n m u c h m o re
v a lu a b le . T h is is th e " b la d d e r e ffe c t" ! R e c e n t1 y , w ith in so m e
o rg a n iz a tio n s, th e re h a s b e e n so m e c o n c e rn a b o u t so lv in g
th is p ro b le m , a s th e se o rg a n iz a tio n s h a v e n o w n o te d th a t
th is m u tu a l c o lla b o ra tio n d e p e n d s o n th e ir " fin a n c ia I
h e a lth " .
In sc e n a rio C , th e d e rm a to lo g ist g e n e ra lly a n d a s
e x p e c te d w a n ts to o ffe r to h is p a tie n t th e b e st a v a ila b le in
te rm s o f h e a lth p ro m o tio n . It is w o rth e m p h a siz in g h e re
th a t o fte n th e d e c isio n a b o u t w h ic h th e ra p e u tic stra te g y
sh o u ld b e a d o p te d d e p e n d s o n th e d ise a se a n d w h o se
re so u rc e s w ill b e u se d (w h o fo o ts th e b ill!). Iffa c e d w ith a
d e rm a to p h y to sis (m y c o sis), th e d e rm a to lo g ist w ill p ro b a b ly
d e c id e th a t th e a d d itio n a l5 % c u re ra te (9 5 % m in u s 9 0 % )
is n o t ju stifie d b y th e d iffe re n c e in th e c o st o f tre a tm e n t
(1 0 0 tim e s). O n th e o th e r h a n d , if fa c e d w ith a m e la n o m a
in situ
(sk in c a n c e r), th is in c re a se in c u re ra te u sin gp ro c e d u re B c o u ld b e ju stifia b le e v e n c o n sid e rin g th e
a d d itio n a l c o st.
R e g a rd in g w h o p a y s th e b ill, th e sa m e e x e rc ise o c c u rs:
fre q u e n tly th e p ro fe ssio n a l in q u ire s w h e th e r th e p a tie n t is
c o v e re d b y th e in su re r fo r p e rfo rm in g a p a rtic u la r p ro c e d u re .
O n c e a g a in , th e h e a lth p ro fe ssio n a l' s ro le a s " a g e n t"
a p p e a rs h e re : h e g e n e ra te s th e d e m a n d o It is a lso w o rth
re m e m b e rin g th a t th e " fin a n c ia I h e a lth " o f o n e p a rty sh o u ld
le a d to w a rd s th e " fin a n c ia I h e a lth " o f th e o th e r p a rty . If w e
a re a im in g fo r a so c ie ty w ith a c a p ita l " 5 " , su c h q u e stio n s
sh o u ld n o lo n g e r b e p o se d . T h e re so u rc e w o u ld h a v e to b e
re g a rd e d a s a n e x tre m e ly p re c io u s th in g a n d sh o u ld b e u se d
in th e sa m e w a y , in d e p e n d e n t1 y o f w h o ta k e s o n th e c o sts.
In sc e n a rio D , m a n y o f th e se p ro b le m s a re re p e a te d .
In th is sc e n a rio , h o w e v e r, w e h a v e th e in v o lv e m e n t o f
in d u strie s re la te d to th e h e a lth se c to r. D ire c tly o r in d ire c tly ,
th e se in d u strie s a re b e in g in c re a sin g ly re q u e ste d to
m a n u fa c tu re h ig h e r-q u a lity p ro d u c ts a t c o sts w h ic h ju stify
th e c h o ic e o f th e se p ro d u c ts'. T h is o c c u rs in th e fie ld o f
m e d ic a tio n s, w h e re it is n o t su ffic ie n t to p ro d u c e , fo r
e x a m p le , a m e d ic a tio n w h ic h is le ss to x ic , m o re e ffic a c io u s
o r e ffe c tiv e , b u t it m u st a lso b e e ffic ie n t, o r in o th e r w o rd s,
th e a d d itio n a l u se o f re so u rc e s m u st b e ju stifie d b y th e
b e n e fit g a in e d , w h e n th is p ro d u c t is c o m p a re d to its d ire c t
c o m p e tito rs. O n c e a g a in , d o c to rs o r h e a lth p ro fe ssio n a ls,
a s " a g e n ts" , n e e d to k e e p th e m se lv e s fa m ilia riz e d w ith th e se
n e w c o n c e p ts so th a t th e y c a n u se th ird -p a rty re so u rc e s in
th e m o st a p p ro p ria te w a y .
T o c o n c lu d e , it is im p o rta n t to e m p h a siz e th a t h e a lth
e c o n o m ic s re q u ire s fo r its p ro p e r im p le m e n ta tio n th e u se
o f re so u rc e s w h ic h a t first sig h t a re n o t in sig n ific a n t. T h e
h e a lth se c to r n e e d s to m o v e in th e g e n e ra l d ire c tio n o f w h a t
to d a y is c a lle d " e v id e n c e -b a se d m e d ic in e " , o r in o th e r
w o rd s, th e tim e h a s c o m e fo r u s to n o lo n g e r a c c e p t
e x p re ssio n s lik e " in m y e x p e rie n c e " , " in m y h a n d s" , " if it
w o rk e d o v e r th e re (a b ro a d ) it m u st w o rk h e re a s w e ll" , " I
a m th e d e c isio n -m a k e r" , a m o n g st o th e rs.
It is im p o rta n t th a t u n iv e rsitie s a n d m e d ic a I sc h o o ls
in c lu d e in th e ir u n d e rg ra d u a te c u rric u lu m th e d isc ip lin e o f
c lin ic a I e p id e m io lo g y , o r e v id e n c e -b a se d m e d ic in e , to
e m p o w e r p ro fe ssio n a ls to g e n e ra te k n o w le d g e th ro u g h
re se a rc h re le v a n t to th e ir lo c a l situ a tio n (a n d w h e n p ro p e rly
c a rrie d o u t th is sh o u ld b e in te rp re te d a s o n e o f th e m o st
v a lu a b le in v e stm e n ts), o r to e m p o w e r th e p ro fe ssio n a l to
k e e p h im se lf u p -to -d a te th ro u g h a p p ro p ria te u se o f th e
sc ie n tific a lly v a lid m a te ria l w h ic h is c o n sta n tly b e in g
p ro d u c e d a n d p u b lish e d (th e re is a lo t o f " sc ie n tific
p o llu tio n " b e in g p u b lish e d in m a jo r in te m a tio n a l jo u rn a ls,
le t a lo n e B ra z ilia n o n e s).
H e a lth e c o n o m ic s d e p e n d s c o m p le te ly o n th e
in fo rm a tio n c o m in g fro m e v id e n c e -b a se d m e d ic in e . O n ly
th u s w ill w e b e in a p o sitio n to m a k e d e c isio n s in th e h e a lth
se c to r w h ic h b e n e fit so c ie ty a s a w h o le in th e fu tu re . In th is
p ro c e ss, a s a m a tte r o f u rg e n c y , d e c isio n s sh o u ld c e a se to
b e p o litic a l a n d sh o u ld in c re a sin g ly b e c o m e b a se d o n g o o d
sc ie n tific in fo rm a tio n .
