Friday, January 28, 2011

Gastric banding included (sorry, no pictures)

I spent one day this week in the ambulatory surgical unit of Hospital São João. They offer numerous procedures such as arthroplasties, gynecological surgeries, hernia repairs, etc. on an outpatient basis for patients meeting strict criteria to manage risk. These include a certain level of health to optimize post-surgical outcomes, a phone to access urgent health care up 24 hours post surgery, an adult family member or caretaker, private transportation, and running water. During my day, I saw three gastric banding procedures.  It turns out that after a patient fails diet and exercise for weight loss, patients with morbid obesity can get public insurance to cover this procedure. I asked my residents what else could be covered, and they say that most things are—they’ve even heard of people “working” the system to have their breasts augmented due to “asymmetry”… Anyway, I thought I would delve a bit further on these unbelievable benefits of the national health program. I present my findings here.

As I mentioned before, the National Health Service of Portugal falls under the responsibility of the Ministry of Health and accounts for approximately 13% of the gross domestic product. As a working resident of Portugal, you are entitled to “free” basic health care under the Portuguese national health system including free essential medicines, free GP appointments, free treatments as well as partially subsidized (0%-60% subsidized) non-essential medical care.

Health Care Benefits: Theoretically, there are no services explicitly excluded from the NHS. That being said, in actuality, some types of care are not available in practice (i.e. 92% of adult dental care was in the private sector). General medical care for the adult population is provided by general practitioners, family physicians, or family care nurses to include services such as prenatal care, women and children, children’s care, family planning, first aid, certification of incapacity to work, home visits, and preventive services, including immunization and screening for breast, cervical and other preventable diseases. Patients are then referred to specialist for secondary and tertiary care services.

Out-of-pocket payment: In recent years, there has been an increasing use of co-payments to make consumers more cost-aware and to decrease abuse of the system.  For a flat rate, you have consultations (primary care and hospital outpatient visits), emergency visits, and home visits. There are also nominal fees for diagnostic tests and therapeutic procedures. Since January 2011, these fees increased to the following:
  • Central hospitals - € 4.60
  • District hospitals -€ 3.10
  • Health Centers - € 2.25

Exemptions of co-payments apply for the elderly, pensioners, or patients with any of the following long list of circumstances (shame on USA):
Pregnant women;
  • Children 12 years of age and under
  • Children and youth with disabilities;
  • Beneficiaries of a monthly allowance for life;
  • Pensioners who receive income not exceeding the national minimum wage, their spouses and dependent minor children;
  • Unemployed, enrolled in job centers, which receive income not exceeding the national minimum wage, their spouses and dependent minor children;
  • Beneficiaries of any provision of nature by shortages, pay for services officers, their spouses and minor children;
  • Residents of nursing homes for children and young people deprived of normal family environment;
  • Workers on behalf of others who receive monthly income not exceeding the national minimum wage, their spouses and minor children;
  • Pensioners with occupational disease and permanent disability
  • Recipients of social integration income;
  • Chronic renal failure;
  • Diabetes;
  • Hemophiliacs;
  • Parkinson’s disease;
  • Tuberculosis;
  • AIDS patients and HIV positive;
  • Oncological patients;
  • Amyloidosis;
  • Hansen's disease;
  • Ankylosing spondylitis;
  • Multiple sclerosis;
  • Benevolent blood donors (provided they have made two donations in the 365 days preceding the date of access to health delivery, or if they are temporarily prevented by proven medical reasons, to donate blood, they have done previously donated five valid, or if they are permanently incapable, for medical reasons or documented age limit for donating blood, have previously made ten donations valid);
  • Chronically mentally ill;
  • Chronic alcoholics and drug addicts, when placed in rehabilitation programs
  • Genetic disease with severe clinical manifestations;
  • Congestive heart failure;
  • Cardiomyopathy;
  • Chronic obstructive pulmonary disease;
  • Chronic active hepatitis;
  • Cirrhosis with severe symptoms;
  • Crippling arthritis;
  • Lupus;
  • Dermatomiose;
  • Paraplegia;
  • Myasthenia gravis;
  • Demyelinating disease;
  • Motor neuron disease;
  • Patients with chronic diseases identified in the Minister of Health who, for medical criteria, call for appointments, tests and treatments are common and potential cause of early disability or significant reduction of life expectancy;
  • Firefighters;
  • Victims of domestic violence;
  • Organ transplant patients;
  • Living donors of organs, cells from bone marrow or hematopoietic stem cell;
  • Potential organ donors of bone marrow cells or hematopoietic progenitor cells, in the provision of health services related to assessing the possibility of donation;
  • Military and ex-armed forces personnel who are permanently disabled;
  • Other cases prescribed by special legislation
Drugs: Doctors are free to prescribe any drug available on the Portuguese drug market, and almost all of them are partially reimbursed or totally paid by the NHS. The co-payments on pharmaceuticals vary from 40% to 100% depending on the therapeutic value of the drug. Full payment is usually expected to those drugs deemed to have little or no clinical value. Pensioners pay a reduced co-payment and the chronically ill are exempt from co-payments.

The following therapeutic classes are always fully covered:
  • anti-diabetics
  • anti-epileptics
  • anti-Parkinson’s
  • anti-neoplasm and immunomodulators
  • growth and anti-diuretic hormones
  • specific drugs for hemodialysis
  • cystic fibrosis treatments
  • glaucoma treatments
  • hemophilia treatments
  • anti-tuberculosis and anti-leprous drugs.
Additionally, all vaccinations in the National Vaccination Program are fully covered.

Excluding the medications above, pharmaceuticals are sold to the public according to the following classification scheme:
  • Tier A - 90%; (ie, hormones and drugs for the treatment of endocrine diseases)
  • Tier B - 69%; (ie, antimicrobials, cardiovascular drugs)
  • Tier C - 37%; (ie, genitourinary system, allergenic)
  • Tier D - 15%.

Obviously health care in Portugal is highly valued, and their culture of strong social systems makes access for even the poorest residents a priority.  However, the economic forecast of the country is questionable as the aging population grows, without robust immigration and a decreasing birth rate. The Ministry of Health will have their work cut out for them to implement a more efficient and sustainable program. When they’ve figured it out, perhaps they can let us in on the secret.

I’ve used the WHO’s HiT paper, the NHS official website (and a few conversations with Portuguese physicians) for this blog post. See below.

Bentes M, Dias CM, Sakellarides C, Bankauskaite, V. Health care systems in transition: Portugal. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.

Portal da Saude. (National Health Service official website)

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