- Email: [email protected]
Financing structure for Mexican health reform in danger
Correspondence
question. The goal of our paper was to show the significant clinical improvement gained by kyphoplasty over conventional care. The radiological data are complex and will be the subject of a further paper. The FREE study design does not allow benefits of deformity correction to be assessed. However, in the KAVIAR Study, and other randomised controlled trials in process, this is being studied to compare the two technologies. DW has received honoraria for consulting from Medtronic Spine LLC, and Cryolife and has received research funding from Medtronic Spine LLC, Zimmer, Apatec, and Cryolife; JVM and LB have received honoraria for consulting from Medtronic Spine LLC; JR is employed by the Swedish National Competence Centre for musculoskeletal disorders at Lund University Hospital, Sweden, which has received compensation for work by Medtronic Spine LLC; SB has received honoraria for consulting from Medtronic Spine LLC and has received consulting or advisory board fees, lecture fees, and research funding or grant support from Amgen, Eli Lilly, Kyphon, Merck, Novartis, Procter & Gamble, SanofiAventis, Servier, and Roche–GlaxoSmithKline.
*Douglas Wardlaw, Jan Van Meirhaeghe, Leonard Bastian, Jonas Ranstam, Steven Boonen, for the Fracture Reduction Evaluation (FREE) Study Investigators [email protected] Woodend Hospital, Aberdeen AB15 6ZQ, UK (DW); Algemeen Ziekenhuis St Jan, Brugge, Belgium (JVM); Klinikum Leverkusen, Leverkusen, Germany (LB); Swedish National Competence Centre for Musculoskeletal Disorders at Lund University Hospital, Lund, Sweden (JR); and Leuven University Division of Geriatric Medicine, Katholieke Universiteit Leuven, Leuven, Belgium (SB) 1
2
3
4
5
1948
Kallmes DF, Jarvik JG. Spinal augmentation research: FREE at last? Lancet 2009; 373: 982–84. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006; 31: 1983–2001. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine 2006; 31: 2747–55. Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 2008; 8: 488–97. Phillips FM, Todd Wetzel F, Lieberman I, Campbell-Hupp M. An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002; 27: 2173–78.
Financing structure for Mexican health reform in danger Since 2006, The Lancet has published extensively on the 2003 Mexican health reform, Seguro Popular. These articles have focused on Seguro Popular’s initial goals and preliminary achievements. Surprisingly, however, although Seguro Popular is largely a financial reform, none of these articles has investigated the degree to which the financing structure of the reform has been properly implemented. An appraisal of the reform’s financial foundations raises questions about its long-term sustainability. Recall that the programme established tripartite financial responsibility for paying insurance premiums: except for the poorest, the premium cost is covered by a family contribution, a state subsidy, and a federal subsidy. The bottom two deciles of the income distribution are exempt from payment. The premium is based on a preliminary costing out of the basic package of services offered in 2004. This premium covered the variable costs of providing services, but did not include any costing of new infrastructure. Separate funds were dedicated for capital investment. What has happened to the insurance premium? Even in 2006, data from The Lancet’s Series suggested that few non-poor families were actually paying the required premium.1 Although the number of families has increased alongside the number of covered services, 97% of families still make no contributions to the premium.2 They are not alone. States have also failed to pay their full share of the premium.3 Furthermore, in 2007, the government reported that 88% of state payments were credited, largely for infrastructure investments.2 This means that money to pay for services is being used to pay for buildings, not all of which even support Seguro Popular services, and none of which was included in the costing of
the package. At the same time, the government’s attempt to control costs by hiring temporary contract medical workers was halted in 2007 when the union won “regularisation”, meaning Seguro Popular workers will eventually become regular union employees with full benefits. Seguro Popular envisioned a reform of Mexican federalism, in which wealthier states would receive less, while poorer and sicker states would receive more resources. 5 years later, however, wealthy states continue to receive far more than poor states (author’s calculations based on official government data), largely because wealthy states still receive non-progressively distributed money alongside the progressive formula introduced in 2004. Unless new revenues are identified, the growth in expenditure across all states will bankrupt the health system. Unfortunately, Seguro Popular’s accomplishments are threatened by the failure to fully transform Mexico’s health system financing. I declare that I have no conflicts of interest.
Jason Lakin [email protected] Harvard School of Public Health, Cambridge, MA 02140, USA 1 Gakidou ER, Lozano E, González-Pier J, et al. Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006; 368: 1920–35. 2 Secretaría de Salud. Sistema de protección social en salud: informe de resultados primer al primer semestre de 2008. México City: Secretaría de Salud, 2008. 3 Urbina M. Sistema de protección social en salud—Seguro Popular en Salud. Evaluación y consistencia de resultados. México City: Coneval, 2008. http://www.coneval.gob.mx/ contenido/eval_mon/1742.pdf (accessed May 13, 2009).
Department of Error Christensen J, Pedersen MG, Pedersen CB, Sidenius P, Olsen J, Vestergaard M. Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. Lancet 2009; 373: 1105–10—In table 4 of this Article (March 28), under the heading “No family history”, the number of people with epilepsy who had severe brain injury should be 111.
www.thelancet.com Vol 373 June 6, 2009
question. The goal of our paper was to show the significant clinical improvement gained by kyphoplasty over conventional care. The radiological data are complex and will be the subject of a further paper. The FREE study design does not allow benefits of deformity correction to be assessed. However, in the KAVIAR Study, and other randomised controlled trials in process, this is being studied to compare the two technologies. DW has received honoraria for consulting from Medtronic Spine LLC, and Cryolife and has received research funding from Medtronic Spine LLC, Zimmer, Apatec, and Cryolife; JVM and LB have received honoraria for consulting from Medtronic Spine LLC; JR is employed by the Swedish National Competence Centre for musculoskeletal disorders at Lund University Hospital, Sweden, which has received compensation for work by Medtronic Spine LLC; SB has received honoraria for consulting from Medtronic Spine LLC and has received consulting or advisory board fees, lecture fees, and research funding or grant support from Amgen, Eli Lilly, Kyphon, Merck, Novartis, Procter & Gamble, SanofiAventis, Servier, and Roche–GlaxoSmithKline.
*Douglas Wardlaw, Jan Van Meirhaeghe, Leonard Bastian, Jonas Ranstam, Steven Boonen, for the Fracture Reduction Evaluation (FREE) Study Investigators [email protected] Woodend Hospital, Aberdeen AB15 6ZQ, UK (DW); Algemeen Ziekenhuis St Jan, Brugge, Belgium (JVM); Klinikum Leverkusen, Leverkusen, Germany (LB); Swedish National Competence Centre for Musculoskeletal Disorders at Lund University Hospital, Lund, Sweden (JR); and Leuven University Division of Geriatric Medicine, Katholieke Universiteit Leuven, Leuven, Belgium (SB) 1
2
3
4
5
1948
Kallmes DF, Jarvik JG. Spinal augmentation research: FREE at last? Lancet 2009; 373: 982–84. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006; 31: 1983–2001. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine 2006; 31: 2747–55. Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 2008; 8: 488–97. Phillips FM, Todd Wetzel F, Lieberman I, Campbell-Hupp M. An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002; 27: 2173–78.
Financing structure for Mexican health reform in danger Since 2006, The Lancet has published extensively on the 2003 Mexican health reform, Seguro Popular. These articles have focused on Seguro Popular’s initial goals and preliminary achievements. Surprisingly, however, although Seguro Popular is largely a financial reform, none of these articles has investigated the degree to which the financing structure of the reform has been properly implemented. An appraisal of the reform’s financial foundations raises questions about its long-term sustainability. Recall that the programme established tripartite financial responsibility for paying insurance premiums: except for the poorest, the premium cost is covered by a family contribution, a state subsidy, and a federal subsidy. The bottom two deciles of the income distribution are exempt from payment. The premium is based on a preliminary costing out of the basic package of services offered in 2004. This premium covered the variable costs of providing services, but did not include any costing of new infrastructure. Separate funds were dedicated for capital investment. What has happened to the insurance premium? Even in 2006, data from The Lancet’s Series suggested that few non-poor families were actually paying the required premium.1 Although the number of families has increased alongside the number of covered services, 97% of families still make no contributions to the premium.2 They are not alone. States have also failed to pay their full share of the premium.3 Furthermore, in 2007, the government reported that 88% of state payments were credited, largely for infrastructure investments.2 This means that money to pay for services is being used to pay for buildings, not all of which even support Seguro Popular services, and none of which was included in the costing of
the package. At the same time, the government’s attempt to control costs by hiring temporary contract medical workers was halted in 2007 when the union won “regularisation”, meaning Seguro Popular workers will eventually become regular union employees with full benefits. Seguro Popular envisioned a reform of Mexican federalism, in which wealthier states would receive less, while poorer and sicker states would receive more resources. 5 years later, however, wealthy states continue to receive far more than poor states (author’s calculations based on official government data), largely because wealthy states still receive non-progressively distributed money alongside the progressive formula introduced in 2004. Unless new revenues are identified, the growth in expenditure across all states will bankrupt the health system. Unfortunately, Seguro Popular’s accomplishments are threatened by the failure to fully transform Mexico’s health system financing. I declare that I have no conflicts of interest.
Jason Lakin [email protected] Harvard School of Public Health, Cambridge, MA 02140, USA 1 Gakidou ER, Lozano E, González-Pier J, et al. Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006; 368: 1920–35. 2 Secretaría de Salud. Sistema de protección social en salud: informe de resultados primer al primer semestre de 2008. México City: Secretaría de Salud, 2008. 3 Urbina M. Sistema de protección social en salud—Seguro Popular en Salud. Evaluación y consistencia de resultados. México City: Coneval, 2008. http://www.coneval.gob.mx/ contenido/eval_mon/1742.pdf (accessed May 13, 2009).
Department of Error Christensen J, Pedersen MG, Pedersen CB, Sidenius P, Olsen J, Vestergaard M. Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. Lancet 2009; 373: 1105–10—In table 4 of this Article (March 28), under the heading “No family history”, the number of people with epilepsy who had severe brain injury should be 111.
www.thelancet.com Vol 373 June 6, 2009