Presentación con preguntas clave sobre el gasto en salud. Quién gasta, cuanto se gasta, quien paga la salud.

1. Gasto en Salud y
Financiamiento
D R . C A R L O S J A V I E R R E G A Z Z O N I

2. Comparación: Gasto annual en
salud, 1980–2006!
$7.000
$6.000
$5.000
$4.000
$3.000
$2.000
$1.000
$0
United
States
Germany
Canada
Netherlands
France
Australia
United
Kingdom
Gasto annual promedio en salud ($US PPP*)

3. Evolución del Gasto en
Salud, EE.UU.
7
6
5
4
3
2
1
0
-­‐1
-­‐2
2000-­‐2007
2007-­‐2010
2010-­‐2013
Crecimiento
anual
promedio
Tasa
anual
promedio
de
crecimiento,
Gasto
Nacional
en
Salud
real,
per
cápita
Elaboración
propia,
en
base
a:
White
House,
November
2013
Total!
Cuidado Hospitalario!
Servicios Profesionales!
Medicamentos!
Cuidados Institucionales!

4. Evolución del Gasto en Salud, EE.UU.
Tomado
de
White
House,
TRENDS
IN
HEALTH
CARE
COST
GROWTH
AND
THE
ROLE
OF
THE
AFFORDABLE
CARE
ACT.
November
2013

5. Gasto en Salud
QUÉ ES EL GASTO EN
SALUD

6. Gasto en Salud
Recursos
Procesos
Resultados
Expresión
Monetaria
Impacto
Social
• Humano
• Económico
Gasto
en
Salud
Gasto>
Componentes:
• Precios
• Uso
(CanZdad)

7. Gasto en Salud
CUÁNTO SE GASTA EN
SALUD

8. Gasto Consolidado* en Salud. Serie Anual 2006 / 2012.En
millones de pesos.
2006 2007 2008 2009 2010 2011 2012
GASTO CONSOLIDADO EN SALUD en
millones de pesos 29.552 38.865 52.912 71.152 88.246 120.753 153.740
Atención pública de la salud 12.871 16.862 22.620 29.420 36.804 50.565 61.639
Obras sociales - Atención de la salud 12.885 16.723 22.727 31.385 38.681 53.160 69.665
INSSJyP - Atención de la salud 3.797 5.280 7.564 10.347 12.761 17.028 22.436
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON
* Gasto Consolidado es Gasto Público más Obras Sociales

9. Gasto Consolidado en Salud por Jurisdicción. Serie Anual
2006 / 2012. En millones de pesos
2006 2007 2008 2009 2010 2011 2012
GASTO CONSOLIDADO EN SALUD
en millones de pesos
29.552 38.865 52.912 71.152 88.246 120.753 153.740
Nacional 13.870 18.386 25.980 37.143 45.870 61.988 81.573
Provincial 13.612 17.874 23.516 30.013 36.862 51.471 63.715
Municipal 2.070 2.605 3.415 3.996 5.514 7.294 8.451
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON

10. Gasto Consolidado en Salud apertura total . Serie Anual
2003 / 2012.En millones de pesos. A pesos corrientes
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
GASTO CONSOLIDADO EN SALUD
Nacional + Provincial+ Municipal 15.980 18.874 23.717 29.552 38.865 52.912 71.152 88.246 120.753 153.740
NACIONAL 7.662 9.172 11.188 13.870 18.386 25.980 37.143 45.870 61.988 81.573
Atención pública de la salud 1.229 1.448 1.564 1.881 2.502 3.484 5.378 6.470 8.613 10.733
Obras sociales - Atención de la salud 4.237 5.243 6.641 8.193 10.604 14.932 21.418 26.639 36.347 48.405
INSSJyP - Atención de la salud 2.196 2.482 2.983 3.797 5.280 7.564 10.347 12.761 17.028 22.436
PROVINCIAL 7.304 8.429 10.903 13.612 17.874 23.516 30.013 36.862 51.471 63.715
Atención pública de la salud 4.733 5.503 7.143 8.920 11.755 15.721 20.046 24.821 34.658 42.455
Obras sociales - Atención de la salud 2.571 2.925 3.760 4.692 6.119 7.795 9.967 12.041 16.813 21.260
INSSJyP - Atención de la salud 0 0 0 0 0 0 0 0 0 0
MUNICIPAL 1.014 1.273 1.626 2.070 2.605 3.415 3.996 5.514 7.294 8.451
Atención pública de la salud 1.014 1.273 1.626 2.070 2.605 3.415 3.996 5.514 7.294 8.451
Obras sociales - Atención de la salud 0 0 0 0 0 0 0 0 0 0
INSSJyP - Atención de la salud 0 0 0 0 0 0 0 0 0 0
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON. Estimaciones propias.

11. Gasto Consolidado en Salud. Serie Anual 2006 / 2012.En
millones de pesos
Gasto consolidado nominal anual en Salud 2006 / 2012-
$ 29.552
$ 38.865
$ 52.912
$ 71.152
180.000
160.000
140.000
120.000
100.000
80.000
60.000
40.000
20.000
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON
en millones de pesos (Total)
$ 88.246
$ 153.740
$ 120.753
0
2006 2007 2008 2009 2010 2011 2012
$
Año

12. Gasto Consolidado en Salud. Año 2012
Distribución Gasto Conosolidado en Salud 2012 en
$ 61.638,97
$ 22.436,10
$ 69.665,12
millones de pesos
Atención pública de la salud
Obras sociales - Atención de la
salud
INSSJyP - Atención de la salud
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON

13. Gasto Consolidado en Salud por Jurisdicción. Año
2012.En millones de pesos
Distribución
Gasto
Conosolidado
en
Salud
por
jurisdicción.
Año
2012
$ 8.451
en
millones
de
pesos
$ 63.715 $ 81.573
Nacional
Provincial
Municipal
Fuente: Sistema SIDIF , Secretaría de Política Económica y Presupuesto Nacional. MECON. Estimaciones propias

14. Gasto Consolidado en Salud. Serie Anual Nominal 2006 /
2012 como % del PBI .En millones de pesos.
2006 2007 2008 2009 2010 2011 2012
PBI precios
corrientes ($) 654.439 812.456
1.032.758 1.145.458
1.442.655
1.842.022
2.164.246
Total Gasto
Consolidado en
Salud 29.552 38.865 52.912 71.152 88.246 120.753 153.740
Gasto consolidado
en Salud como %
4,5% 4,8% 5,1% 6,2% 6,1% 6,6% 7,1%
del PBI
Fuente: Sistema SIDIF y Secretaría de Política Económica, MECON. INDEC. Estimaciones propias.

15. Aportes de salud, Argentina,
por sector, 2012. F Tobar

16. Gasto en Salud
QUIENES GASTAN

17. Gasto en Salud
QUIENES GASTAN>
LAS PERSONAS DE EDAD

18. GASTO RELATIVO EN SALUD Y EDAD
Gasto relativo
6
5
4
3
2
1
0
Gasto relativo per cápita en salud, por edades, EE.UU
1999
Edad 35-44 años=1
Meara E, White C, Cutler DM, 2003
0-5 6-14 15-24 25-34 35-44 45-54 55-64 65-74 75+

19. Concentración del Gasto
ParFcipación
en
el
Gasto
en
Salud,
según
canFdad
de
población.
US,
población,
2005-­‐2006;
MEPS
(Cohen,
Rohde,
2009)
18,7
44
59,5
81,9
100
90
80
70
60
50
40
30
20
10
0
0
Top 1%
Top 5%
Top 10%
Top 25%
Top 50%
100
Porcentaje
del
Gasto
Total
en
Salud
Porcentaje
de
la
población
según
nivel
de
gasto
(percenFlo)
18,7
44
59,5
81,9
95,7
Top 1%
Top 5%
Top 10%
Top 25%
Top 50%

20. Predictores de Gasto
25,3
ParFcipación
en
el
Gasto
en
Salud,
según
Edad.
US,
población,
2005-­‐2006;
MEPS
(Cohen,
Rohde,
2009)
36,6
13,2
45,1
35,1
26,8
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Población
General
Top
5%
Top
6-­‐10%
Top
11-­‐25%
Porcentaje
de
población
según
grupo
etario
PercenFlo
de
Gasto
65
y
más
45-­‐64
30-­‐44
18-­‐29
0-­‐17

21. Concentración del Gasto
• El 10% de la población
concentra 60% del gasto
Personas:
-Mayores de 45 años de edad
-Que están más enfermas

22. Esperanza a los 75 años
12
11,5
11
10,5
10
9,5
Años
de
vida
promedio
a
parFr
de
los
75
años
de
edad
EE.UU.
ExpectaFva
de
vida
a
los
75
años
CDC.
Health,
United
States
2009
Web
Update

23. Gasto en Salud
QUIENES GASTAN>
LOS MÁS POBRES

24. by age 65 years most were
However, in absolute terms,
multimorbidity were younger than
and older (210 500 vs 194 966),
more morbidities on average
of multimorbidity increased
Multimorbilidad y
deprivation of the area in which patients
3–19·6, in the most affl uent
·4, in the most deprived;
3–4·9; table 1). However, this
status
interpreted with caution because the
deprived areas was, on average,
years [IQR 21–53] in the most
IQR 22–58] in the most affl uent
more deprived areas were more
than were those living in the
ages, apart from those aged
2). Young and middle-aged
deprived areas had rates of
to those aged 10–15 years older
gure 2 and appendix).
of all patients, and 36·0%
multimorbidity, had both a
health disorder. The prevalence of
comorbidity was higher in
90
80
70
60
50
40
30
20
10
4·0
3·0
8·0
12·0
16·8
21·2
26·8
36·8
45·4
54·2
15–19
30–34
40–44
60–64
disorder as the outcome (table 2), we noted a non-linear
association with age, so we included an age-squared term
64·1
70·6
76·5
79·4
80·6
82·9
76·6
69·1
58·3
46·5
34·8
9·8
13·4
18·3
26·8
6·3 7·9
4·8
00–4
5–9
10–14
20–24
25–29
35–39
45–49
50–54
55–59
65–69
70–74
80–84
75–79
≥85
Age group (years)
Patients with multimorbididty (%)
Socioeconomic
status
10
98765432
1
Figure 2: Prevalence of multimorbidity by age and socioeconomic status
On socioeconomic status scale, 1=most affl uent and 10=most deprived.
Barne`
K,
et
al.
Epidemiology
of
mulZmorbidity
and
implicaZons
for
health
care,
research,
and
medical
educaZon:
a
cross-­‐secZonal
study.
Lancet,
May10,
2012
DOI:10.1016/S0140-­‐6736(12)60240-­‐2

25. Gasto en Salud
QUIENES GASTAN>
LA SALUD Y LOS MÉDICOS

26. Efectos de los cuidados
sobre la salud
• 3.A. Densidad de Médicos
• 3.B. Expansión de la Cobertura
• 3.C. Mayor Complejidad

27. 3.a. Densidad de médicos
• La mayor densidad de médicos se asocia a una
menor mortalidad materna e infantil,
independientemente de otras variables.
Sudhir
Anand,
Till
Bärnighausen.
Human
resources
and
health
outcomes:
cross-­‐country
econometric
study.
Lancet
2004;
364:
1603–09

28. Dependent variables Maternal mortality Infant mortality Under-five mortality Maternal mortality Infant mortality Under-five mortality
Independent variables
Constant 13·596 10·362 9·234 10·302 9·009 7·598
Gross national income per person –0·776 –0·647 –0·660 –0·403 –0·500 –0·488
Income poverty .. .. .. 0·158 0·103 0·129
Female adult literacy –0·292 –0·245 –0·256 –0·309 –0·272 –0·281
Doctor density –0·325 –0·183 –0·225 –0·386 –0·174 –0·216
Nurse density –0·162 –0·062 –0·047 –0·102 –0·044 –0·024
n 117 117 117 83 83 83
R2 0·808 0·827 0·835 0·823 0·799 0·808
F 117·628 133·807 141·218 71·695 61·331 64·855
p <0·0001 <0·0001 <0·0001 <0·0001 <0·0001 <0·0001
All dependent and independent variables were transformed into natural logarithms for the regressions. The numbers in the cells are b (regression coefficient), tb (t value of b), and p value.
Table 3: Multiple regression equations with doctors and nurses as separate independent variables
Introduction
Human resources for health are clearly a prerequisite for
health care, with most medical interventions needing the
services of doctors, nurses, or other types of health
Results
Regressions without income poverty Regressions with income poverty
(13·999) (16·264) (13·996) (8·390) (9·573) (7·741)
<0·0001 <0·0001 <0·0001 <0·0001 <0·0001 <0·0001
(–7·326) (–9·307) (–9·174) (–2·959) (–4·784) (–4·484)
<0·0001 <0·0001 <0·0001 0·0041 <0·0001 <0·0001
(1·925) (1·633) (1·972)
0·0580 0·1065 0·0522
(–1·351) (–1·726) (–1·742) (–1·471) (–1·689) (–1670)
0·1793 0·0872 0·0843 0·1454 0·0952 0·0990
(–4·450) (–3·822) (–4·534) (–5·230) (–3·079) (–3·657)
<0·0001 0·0002 <0·0001 <0·0001 0·0029 0·0005
(–2·034) (–1·186) (–0·874) (–1·250) (–0·702) (–0·364)
0·0443 0·2380 0·3838 0·2150 0·4848 0·7170
account for mortality outcomes. Robinson and Wharrad4,5
found that a high density of doctors has a beneficial effect
on maternal, infant, and under-five mortality. By contrast,
Cochrane and colleagues6 showed doctor density had an
As we expected, the human resources for health
Lancet 2004; 364: 1603–09
See Comment page 1558
University of Oxford,
Department of Economics,
Oxford, UK (Prof S Anand DPhil);
Harvard University, Global
Equity Initiative, Cambridge,
MA, USA (Prof S Anand); and
Harvard School of Public
Health, Department of
Population and International
Health, Boston, MA, USA
(T Bärnighausen MD)
Correspondence to:
Prof Sudhir Anand, St Catherine’s
College, Oxford OX1 3UJ, UK
sudhir.anand@economics.ox.
ac.uk
Human resources and health outcomes: cross-country
econometric study
Sudhir Anand, Till Bärnighausen
Summary
Background Only a few studies have investigated the link between human resources for health and health outcomes, and
they arrive at different conclusions. We tested the strength and significance of density of human resources for health
with improved methods and a new WHO dataset.
Methods We did cross-country multiple regression analyses with maternal mortality rate, infant mortality rate, and
under-five mortality rate as dependent variables. Aggregate density of human resources for health was an independent
variable in one set of regressions; doctor and nurse densities separately were used in another set. We controlled for the
effects of income, female adult literacy, and absolute income poverty.
Findings Density of human resources for health is significant in accounting for maternal mortality rate, infant mortality
rate, and under-five mortality rate (with elasticities ranging from –0·474 to –0·212, all p values !0·0036). The
elasticities of the three mortality rates with respect to doctor density ranged from –0·386 to –0·174 (all p values
!0·0029). Nurse density was not associated except in the maternal mortality rate regression without income poverty
(p=0·0443).
Interpretation In addition to other determinants, the density of human resources for health is important in accounting
for the variation in rates of maternal mortality, infant mortality, and under-five mortality across countries. The effect of
this density in reducing maternal mortality is greater than in reducing child mortality, possibly because qualified
medical personnel can better address the illnesses that put mothers at risk. Investment in human resources for health
must be considered as part of a strategy to achieve the Millennium Development Goals of improving maternal health
and reducing child mortality.
Mortalidad
materna,
e
InfanFl
:
GDP/Cápita;
Densidad
de
Médicos

29. 3.b. Expansión de la
cobertura
• El aumento de la cobertura en salud, se asocia a
reducciones de la mortalidad de la población, y a
un incremento de la accesibilidad.

30. Medicare y medicaid
E l
C a s o
M e d i c a i d
• Hay estados que vienen expandiendo el Medicaid desde el
año 2000.
• Esa política: ¿cambió la mortalidad?
Sommers
BD,
Baicker
K,
Epstein
AM.
Mortality
and
access
to
care
among
adults
ager
State
Medicaid
expansions.
N
Engl
J
Med,
July
25,
2012

31. Diseño
• -Mortalidad
adultos ⁄
• -Percepción de
salud ⁄
• -Accesibilidad ⁄
Expansión
del
Medicaid:
• Jóvenes
19
–
64
años
• Sin
hijos
• Ingresos
<100%
línea
de
pobreza
Sommers
BD,
Baicker
K,
Epstein
AM.
Mortality
and
access
to
care
among
adults
ager
State
Medicaid
expansions.
N
Engl
J
Med,
July
25,
2012
5
años
5
años
• Arizona
• Maine
• New
York
• N
Hampshire
• Pennsylvania
• Nevada

32. Resultados
• Luego de la expansión del Medicaid:
1. Reducción de la mortalidad.
• Reducción relativa del 6,1% de la mortalidad (Estados con
expansión del Medicaid versus controles).
• Reducción de la mortalidad luego de la expansión del
Medicaid de 25,4 muertes/100.000.
2. Aumento de la accesibilidad.
3. Mejoría de la autopercepción de
salud.
Sommers
BD,
Baicker
K,
Epstein
AM.
Mortality
and
access
to
care
among
adults
ager
State
Medicaid
expansions.
N
Engl
J
Med,
July
25,
2012

33. 3.c. Efecto de la
complejidad
• La mayor complejidad hospitalaria se asocia a
reducciones de la mortalidad.

34. Volumen hospitalario y mortalidad!
La complejidad médica salva vidas, es más costosa, y agrega calidad
N Engl J Med 2010;362:1110-8

35. Calidad de Atención en Adultos
• 6.712
personas
• Adultos
• 12
ciudades
USA
• Contacto
tel.
• Acceso
a
Historias
clínicas
30
Condiciones
seleccionadas
agudas
y
crónicas
439
indicadores
de
calidad
de
atención
Tratamientos
y
medidas
prevenZvas
PARA CADA CONDICIÓN:
• Medición de tratamiento
recibido
• Comparación con tratamiento
recomendado
1998
2000
RAND RESEARCH AREAS
THE ARTS
CHILD POLICY
CIVIL JUSTICE
EDUCATION
ENERGY AND ENVIRONMENT
HEALTH AND HEALTH CARE
INTERNATIONAL AFFAIRS
NATIONAL SECURITY
POPULATION AND AGING
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
SUBSTANCE ABUSE
TERRORISM AND
HOMELAND SECURITY
TRANSPORTATION AND
INFRASTRUCTURE
WORKFORCE AND WORKPLACE
The Health Insurance Experiment
A Classic RAND Study Speaks to the Current
Health Care Reform Debate
After decades of evolution and
experiment, the U.S. health care
system has yet to solve a funda-mental
challenge: delivering quality
health care to all Americans at an aff ordable
price. In the coming years, new solutions will
be explored and older ideas revisited. One
idea that has returned to prominence is cost
sharing, which involves shifting a greater
share of health care expense and responsibil-ity
onto consumers. Recent public discussion
of cost sharing has often cited a landmark
RAND study: the Health Insurance Experi-ment
(HIE). Although it was completed over
two decades ago, in 1982, the HIE remains
the only long-term, experimental study of cost
sharing and its eff ect on service use, quality of
care, and health. Th e purpose of this research
brief is to summarize the HIE’s main fi ndings
and clarify its relevance for today’s debate.
Our goal is not to conclude that cost sharing is
Key fi ndings:
• In a large-scale, multiyear experiment,
participants who paid for a share of their
health care used fewer health services
than a comparison group given free care.
• Cost sharing reduced the use of both
highly effective and less effective services
in roughly equal proportions. Cost sharing
did not signifi cantly affect the quality of
care received by participants.
• Cost sharing in general had no adverse
effects on participant health, but there
were exceptions: free care led to improve-ments
in hypertension, dental health,
vision, and selected serious symptoms. These
improvements were concentrated among
the sickest and poorest patients.
McGlynn
EA,
Asch
SM,
Adams
J,
Keesey
J,
Hicks
J,
DeCristofaro
A,
Kerr
EA.
The
Quality
of
Health
Care
Delivered
to
Adults
in
the
United
States.
N
Engl
J
Med
2003;348:2635-­‐45.

36. Calidad de Atención
Proporción
del
tratamiento
teóricamente
recomendado
y
EE.UU.,
12
áreas
metropolitanas,
2003.
RAND,
The
First
NaZonal
Report
Card
on
Quality
of
45,1
45,1
efecZvamente
recibido
por
los
pacientes.
46,5
43,9
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
General
Prevención
Agudo
Crónico
Tipo
de
tratamiento
Health
Care
in
America
No
recivido
Recivido
RAND RESEARCH AREAS
THE ARTS
CHILD POLICY
CIVIL JUSTICE
EDUCATION
ENERGY AND ENVIRONMENT
HEALTH AND HEALTH CARE
INTERNATIONAL AFFAIRS
NATIONAL SECURITY
POPULATION AND AGING
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
SUBSTANCE ABUSE
TERRORISM AND
HOMELAND SECURITY
TRANSPORTATION AND
INFRASTRUCTURE
WORKFORCE AND WORKPLACE
The Health Insurance Experiment
A Classic RAND Study Speaks to the Current
Health Care Reform Debate
After decades of evolution and
experiment, the U.S. health care
system has yet to solve a funda-mental
challenge: delivering quality
health care to all Americans at an aff ordable
price. In the coming years, new solutions will
be explored and older ideas revisited. One
idea that has returned to prominence is cost
sharing, which involves shifting a greater
share of health care expense and responsibil-ity
onto consumers. Recent public discussion
of cost sharing has often cited a landmark
RAND study: the Health Insurance Experi-ment
(HIE). Although it was completed over
two decades ago, in 1982, the HIE remains
the only long-term, experimental study of cost
sharing and its eff ect on service use, quality of
care, and health. Th e purpose of this research
brief is to summarize the HIE’s main fi ndings
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 eff ects so that
Key fi ndings:
• In a large-scale, multiyear experiment,
participants who paid for a share of their
health care used fewer health services
than a comparison group given free care.
• Cost sharing reduced the use of both
highly effective and less effective services
in roughly equal proportions. Cost sharing
did not signifi cantly affect the quality of
care received by participants.
• Cost sharing in general had no adverse
effects on participant health, but there
were exceptions: free care led to improve-ments
in hypertension, dental health,
vision, and selected serious symptoms. These
improvements were concentrated among
the sickest and poorest patients.

37. Calidad de Atención
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Proporción
del
tratamiento
teóricamente
recomendado,
efecFvamente
recibido
por
los
pacientes.
EE.UU.,
12
áreas
metropolitanas,
2003.
RAND,
The
First
NaZonal
Report
Card
on
Quality
of
Health
Care
in
America
No
recivido
Recivido
RAND RESEARCH AREAS
THE ARTS
CHILD POLICY
CIVIL JUSTICE
EDUCATION
ENERGY AND ENVIRONMENT
HEALTH AND HEALTH CARE
INTERNATIONAL AFFAIRS
NATIONAL SECURITY
POPULATION AND AGING
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
SUBSTANCE ABUSE
TERRORISM AND
HOMELAND SECURITY
TRANSPORTATION AND
INFRASTRUCTURE
WORKFORCE AND WORKPLACE
The Health Insurance Experiment
A Classic RAND Study Speaks to the Current
Health Care Reform Debate
After decades of evolution and
experiment, the U.S. health care
system has yet to solve a funda-mental
challenge: delivering quality
health care to all Americans at an aff ordable
price. In the coming years, new solutions will
be explored and older ideas revisited. One
idea that has returned to prominence is cost
sharing, which involves shifting a greater
share of health care expense and responsibil-ity
onto consumers. Recent public discussion
of cost sharing has often cited a landmark
RAND study: the Health Insurance Experi-ment
(HIE). Although it was completed over
two decades ago, in 1982, the HIE remains
the only long-term, experimental study of cost
sharing and its eff ect on service use, quality of
care, and health. Th e purpose of this research
brief is to summarize the HIE’s main fi ndings
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 eff ects so that
Key fi ndings:
• In a large-scale, multiyear experiment,
participants who paid for a share of their
health care used fewer health services
than a comparison group given free care.
• Cost sharing reduced the use of both
highly effective and less effective services
in roughly equal proportions. Cost sharing
did not signifi cantly affect the quality of
care received by participants.
• Cost sharing in general had no adverse
effects on participant health, but there
were exceptions: free care led to improve-ments
in hypertension, dental health,
vision, and selected serious symptoms. These
improvements were concentrated among
the sickest and poorest patients.

38. Causas de Gasto Total
40
30
20
10
0
109
U$S
50
Gasto
Total,
10
primeras
causas,
Adultos,
US
2008
Center
for
Financing,
Access,
and
Cost
Trends,
AHRQ,
Household
Component
of
the
Medical
Expenditure
Panel
Survey,
2008
Mujeres
Hombres

39. Gasto en Salud
QUIENES GASTAN>
LOS MEDICAMENTOS Y
TECNOLOGÍA

40. Gasto en Medicamentos
22,5
15,1
12,3
8,7
8,4
25
20
15
10
5
0
DBT y DLP Analgésicos,
Anticonvulsivos,
Antiparkinson
Cardiovascular Gastrointestinal Psicotrópicos
(%)
del
total
prescripto
ambulatorio
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
Top
5
33%
Gasto
Ambulatorio

41. Tecnología
Tecnología y Salud
65 años
45 años
15 años
Nacim
180.000
160.000
140.000
120.000
100.000
80.000
60.000
40.000
20.000
0
1960
1970
1980
1990
2000
Costo por año de vida ganado (U$S)
Cutler DM, Rosen AB, Vijan S. N Engl J
G
=
Q
.
P
Med 2006
Q
• Demanda
P
de
salud
• Tecnología/
Metodología
• Mercado/Regulac.
• Tecnología/
Metodología

42. Gasto en Salud
QUIENES PAGAN>
EL ESTADO

43. Gobierno y gasto en salud PERSPECTIVE
Payment Source Since redistribution greater role systems of other it does in the is an implication egalitarian ethos Europe, Canada, New Zealand. to the present, have commented role of individualism States than is no consensus Possible to the phenomenon heterogeneity the revolutionary Government of Funds (%)
90
80
70
60
50
40
30
20
10
0
Private
Government
1960 1970 1980 1990 2000 2007
Source of Funds for Personal Health Care Expenditures in the United States, 1960–2007.
VR
Fuchs.
Government
Payment
for
Health
Care
—
Causes
and
Consequences.
N
Engl
J
Med
2010;
363:
2181-­‐83
turers of drugs, devices, and
countries that have a per capita

44. Gobierno y gasto en salud
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ParFcipación
en
el
gasto
personal
en
salud,
según
fuente
de
financiamiento,
EE.UU.
1960
1970
1980
1990
2000
2007
Privado
Gobierno
VR
Fuchs.
Government
Payment
for
Health
Care
—
Causes
and
Consequences.
N
Engl
J
Med
2010;
363:
2181-­‐83

45. Public Private
EE.UU.
posee:
-­‐Menor
parZcipación
pública
en
el
gasto
en
salud.
-­‐Pero
mayor
gasto
total
en
salud
0 2 4 6 8 10 12 14 16 18
United States
Netherlands (2)
France
Germany
Denmark
Canada
Switzerland
Austria
Belgium (1)
New Zealand
Portugal (2008)
Sweden
United Kingdom
Iceland
Greece (2007)
Norway
Ireland
OECD
Spain
Italy
Slovenia
Finland
Slovak Republic
Australia (2008)
Japan (2008)
Chile
Czech Republic
Israel
Hungary
Poland
Estonia
Korea
Luxembourg (2008)
Mexico
Turkey (2008)
GASTO TOTAL EN SALUD, COMO PORCENTAJE DEL PBI, 2009. OECD

46. Gasto en Salud
GASTO EN SALUD Y
ECONOMÍA

47. Gasto en Salud
• PBI=C+G+I+(X-M)=DA=Y
– El gasto en salud es una fracción del PBI
– Pero todo país gasta todo su PBI
– Considerar: “valor para la sociedad”
• Eficiencia
del
gasto,
en
relación
al
“valor
agregado”
• Costo laboral
– Pero “salud”, es parte de los costos de
salario
• Relacionar
con
“producZvidad”
Fuchs
VR.
Health
care
expenditure
reexamined.
Ann
Intern
Med
2005;
143:
76-­‐8

48. 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)
incenZvado
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

49. Particularidades del Gasto en
Salud
1. Rol en las cuentas públicas
– Un peso gastado en salud no tiene efectos
fiscales diferentes de cualquier otro gasto
público
– Pero…
• Como
es
“esencial”,
obliga
al
gasto:
¿Cómo
gastar?
• El
aumento
del
gasto
en
salud,
se
financia
con
impuestos,
con
efectos
en
la
economía
• Tragedia
de
los
comunes
Fuchs VR. Health care is different-That’s why expenditure matters. JAMA 2010; 303: 1859-1860

50. Particularidades del Gasto en
Salud
2. Incertidumbre
• Riesgo
– Frecuencia de eventos
– Eventos más costosos
– Población:
• Más
enferma
• Más
demandante
de
servicios
• Incertidumbre
– Concentración del riesgo
– Criterio longitudinal
– Predictores de eventos: Predictores de gasto
Fuchs VR. Health care is different-That’s why expenditure matters. JAMA 2010; 303: 1859-1860

51. Gasto en salud y PBI
PERSPECTIVE potencial
When the Cost Curve Bent
Prescription drugs
Hospital care
Physician and clinical
services
Non–personal health
care
Other personal health
care
Total NHE
Net cost of private Recession
insurance
Medicare Part D
prescription-drug
coverage
Net cost of private
insurance and spending
on structures
and equipment
Spending Growth in Excess of Potential GDP (%)
4
3
2
1
0
−1
−2
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Figure 1. Growth of National Health Expenditure (NHE) in Excess of Potential Gross Domestic Product (GDP), with Component Effects.
The net cost of private insurance (a major contributor to increased excess spending in 2003 and reduced excess spending in 2008 and 2009) is premium
revenues minus health care Roehrig
payments, C,
whereas Turner
spending A,
Hughes-­‐on structures Cromwick
and equipment P,
Miller
represents G.
When
investments the
Cost
in Curve
health care Bent
delivery —
Pre-­‐systems. Recession
Medicare
Part D, implemented in 2006, introduced prescription-drug coverage Moderafor Zthe on
first in
Health
time to Medicare Care
Spending.
beneficiaries N
and Engl
was J
a Med,
major August
cause of increased
8,
2012
excess spending. Spending estimates are from Altarum Health Sector Economic Indicators. Estimates of potential GDP are from the Congressional
Budget Office. Growth rates for each month are computed relative to the same month a year earlier, smoothed by means of a 3-month moving average.

52. Dinero público a la salud
Producción
$
Impuestos
Gobierno
Gasto
Salud
Gasto
en
Salud
Gasto
Público
Precio
Uso
(CanFdad)
Gasto
Público
-­‐Cuanto
mayor
la
parZcipación
del
Estado
en
el
gasto
en
salud,
mayor
necesidad
de
contención
de
costos

53. Gasto en salud y déficit soberano

54. Costo de salud y economía
100
90
80
70
60
50
40
30
20
10
0
x
x
+
1
Costo
en
Salud
P e r í o d o
¿Quién
asume
el
aumento?
• EL
SALARIO
DEL
TRABAJADOR?
o Mayor
cuota?
o Co-­‐pagos?
• EL
INGRESO
DEL
EMPRESARIO?
o Mayor
cuota
patronal?
• EL
ESTADO?
o Más
impuestos?
Eithoven
AC,
Fuchs
VR.
Employment-­‐based
health
insurance:
past,
present,
and
future.
Health
Affairs
2006;
25:1538-­‐1547

55. Costo de salud y economía
100
90
80
70
60
50
40
30
20
10
0
x x + 1
Costo en Salud
Período
¿Quién
asume
el
aumento?
• EL
SALARIO
DEL
TRABAJADOR?
o Mayor
cuota
o Co-­‐pagos
Eithoven
AC,
Fuchs
VR.
Employment-­‐based
health
insurance:
past,
present,
and
future.
Health
Affairs
2006;
25:1538-­‐1547

56. Costo de salud y economía
100
90
80
70
60
50
40
30
20
10
0
x x + 1
Costo en Salud
Período
¿Quién
asume
el
aumento?
• EL
INGRESO
DEL
EMPRESARIO?
o Mayor
cuota
patronal
Eithoven
AC,
Fuchs
VR.
Employment-­‐based
health
insurance:
past,
present,
and
future.
Health
Affairs
2006;
25:1538-­‐1547

57. Costo de salud y economía
100
90
80
70
60
50
40
30
20
10
0
x x + 1
Costo en Salud
Período
¿Quién
asume
el
aumento?
• EL
ESTADO?
o Más
impuestos
Eithoven
AC,
Fuchs
VR.
Employment-­‐based
health
insurance:
past,
present,
and
future.
Health
Affairs
2006;
25:1538-­‐1547

58. Gasto en salud
NO HAY NINGUNA RAZÓN PARA
DEFINIR ARBITRARIAMENTE UN
NIVEL DE GASTO EN SALUD.
SÍ ES OBLIGATORIO PRETENDER
OBTENER MAYOR VALOR POR DICHO
GASTO.
Fuchs
VR.
Health
care
expenditure
reexamined.
Ann
Intern
Med
2005;
143:
76-­‐8

59. Gasto en Salud
PAGO DE LA SALUD DE
TODOS>NECESIDAD Y
POSIBILIDAD

60. Ley del cuidado inverso
“ … l a d i s p o n i b i l i d a d
de cuidados médicos
varía inversamente
con la necesidad de
los mismos en la
población, hecho que
se magnifica en
operando fuerzas de
mercado…”
Accesibilidad
Ley
del
cuidado
inverso
en
Necesidad
salud
Hart JT. The inverse care law. Lancet 1971; i:405-412

61. However, in absolute terms,
multimorbidity were younger than
older (210 500 vs 194 966),
more morbidities on average
multimorbidity increased
of the area in which patients
19·6, in the most affl uent
Multimorbilidad y
in the most deprived;
4·9; table 1). However, this
status
interpreted with caution because the
deprived areas was, on average,
years [IQR 21–53] in the most
22–58] in the most affl uent
deprived areas were more
than were those living in the
ages, apart from those aged
2). Young and middle-aged
deprived areas had rates of
those aged 10–15 years older
gure 2 and appendix).
of all patients, and 36·0%
multimorbidity, had both a
disorder. The prevalence of
comorbidity was higher in
90
80
70
60
50
40
30
20
10
4·0
3·0
8·0
12·0
16·8
21·2
26·8
36·8
45·4
54·2
15–19
30–34
40–44
60–64
disorder as the outcome (table 2), we noted a non-linear
association with age, so we included an age-squared term
64·1
70·6
76·5
79·4
80·6
82·9
76·6
69·1
58·3
46·5
34·8
9·8
13·4
18·3
26·8
6·3 7·9
4·8
00–4
5–9
10–14
20–24
25–29
35–39
45–49
50–54
55–59
65–69
70–74
80–84
75–79
≥85
Age group (years)
Patients with multimorbididty (%)
Socioeconomic
status
10
9876543
2
1
Figure 2: Prevalence of multimorbidity by age and socioeconomic status
On socioeconomic status scale, 1=most affl uent and 10=most deprived.
Barne`
K,
et
al.
Epidemiology
of
mulZmorbidity
and
implicaZons
for
health
care,
research,
and
medical
educaZon:
a
cross-­‐secZonal
study.
Lancet,
May10,
2012
DOI:10.1016/S0140-­‐6736(12)60240-­‐2

62. Mortalidad infantil>Inequidad
@RegaCarlos
6,9
7,4
8,3
8,9
8,9
8,9
9,4
9,5
9,7
9,8
9,9
10,3
10,8
10,9
11,3
11,4
11,6
11,9
12
12,9
13,3
13,7
14,1
14,4
17,3
Neuquén
T del Fuego
CABA
Catamarca
La Pampa
Santa Cruz
Río Negro
Mendoza
Córdoba
Chubut
San Juan
Santa Fe
Entre Ríos
San Luis
Misiones
Buenos Aires
S del Estero
24 partidos GBA
Jujuy
Salta
Chaco
La Rioja
Tucumán
Corrientes
Formosa
Mortalidad Infantil, año 2012. Defunciones <1año/1.000nv
Elaboración propia en base a MSN, Anuario 2014

63. Salud>Inequidad
75
Esperanza de vida al nacer (años)
71
69
CABA
Pcia Bs As
Chaco
Varones
Período 2008-2010. INDEC, erie Análisis Demográfico no 37.
@RegaCarlos
5 años de diferencia

64. POBREZA E INEQUIDAD!
100
90
80
70
60
50
40
30
20
10
0
Participación (%) del 10% más rico en la riqueza
total del país
Participación porcentual del 10% más rico sobre la riqueza total del país
Francia
UK
USA
Suecia
Décadas
Fuente: Elaboración propia en base a Thomas Piketty. The Capital in the 21st Century. Harvard
University Press - March 2014 http://piketty.pse.ens.fr/capital21c

65. Inequidad en Perspectiva
Desigualdad en el ingreso: Europa vs. EE.UU,
1900-2010
@RegaCarlos
50%
45%
40%
35%
30%
25%
U.S.
Europe
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
Participación del 10% más rico en el
ingreso total
Sources and series: see piketty.pse.ens.fr/capital21c.

66. Inequidad y Salario Mínimo
Salario mínimo, United States, 1950-2013
,
@RegaCarlos
$12,00
$10,80
$9,60
$8,40
$7,20
$6,00
$4,80
$3,60
$2,40
$1,20
$0,00
Minimum wage in 2013 dollars
Minimum wage in current dollars
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
Salario mínimo/hora de trabajo
Sources and series: see piketty.pse.ens.fr/capital21c.

67. Inequidad y Capital
Retorno al capital luego de impuestos, Vs. Crecimiento del
producto mundial, desde la antigüedad hasta 2100
Pure rate of return to capital (after
tax and capital losses)
Growth rate of world output g
@RegaCarlos
6%
5%
4%
3%
2%
1%
0%
Tasa anual de retorno (capital) o de
crecimiento (GDP)
Sources and series : see piketty.pse.ens.fr/capital21c

68. Gasto en salud
¿QUIÉN VA A PAGAR?

69. Gasto en Salud
GASTO EN SALUD Y
VALOR

70. Gasto en Salus>Eficiencia
Gasto
en
Salud
y
Mortalidad<5
años;
100=año
2000
Gasto
salud,
PPP-­‐U$/capita,
total,
y
Mortalidad
en
<5
años-­‐
WHO
Brasil
2008
ArgenZna
2008
Chile
2008
Base,
año
2000
Hungría
2008
170
160
150
140
130
120
110
100
55
60
65
70
75
80
85
90
95
100
Gasto
en
salud/cápita
$-­‐PPP
Mortalidad
en
<5
años

71. Costo-eficiencia
Ø Gasto = Cantidad x Precio
B
A
250
200
150
100
50
0
0
20
40
60
80
100
Nivel de
Gasto
Nivel de salud

72. Más de lo mismo, o mejor
B
A
250
200
150
100
50
0
rendimiento
0
20
40
60
80
100
Nivel de
Gasto
Nivel de salud

73. Optimización del gasto
• Mayor eficiencia o menor precio
B
A
250
200
150
100
50
0
0
50
100
Gasto
salud
Menor
precio
Más
eficiencia

74. Optimización del gasto
B
A
250
200
150
100
50
0
PRECIO
0
50
100
Gasto
salud
B
A
250
200
150
100
50
0
EFICIENCIA
0
50
100
$
Menor
precio
$
Más
resultados

75. La Tragedia de lo Común
Garret Harding. The tragedy of the commons. Science 1968; 162: 1243
Farik Fadul. The Tragedy of the Commons Revisited. NEJM, August 26th, 2009;