Stimulating retrogression?

Stimulating retrogression?

Sergio da Silva Saraiva^I; Rafael Henriques Candiago^I; Veralice Maria Gonçalves^II; Paulo Belmonte-de-Abreu^III

^IPsychiatrist, Graduate Program in Medical Sciences: Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^IISystem analyst, Graduate Program in Medical Sciences: Psychiatry, UFRGS, Porto Alegre, RS, Brazil

^IIICoordinator, Graduate Program in Psychiatry, UFRGS, Porto Alegre, RS, Brazil

^{Correspondence}

Dear Editor,

The purpose of writing this letter is to call attention to the risk of exacerbation of a public health problem that was previously highlighted in the Revista de Psiquiatria do Rio Grande do Sul 3 years ago in the article "Psychiatric reform in Rio Grande do Sul: an analysis of history, economy and the impact of 1992 legislation",¹ regarding the lack of an alternative network of psychiatric beds to replace the beds that were not available anymore as a consequence of the psychiatric reform. At the time of its publication, this study showed that the reduction of 35% in the number of psychiatric beds in the state of Rio Grande do Sul, which was put into practice as a consequence of the State Law no. 9716/1992, had not been compensated by the creation of a network of full care in mental health. More recently, this situation has been at risk of exacerbation due to a decision of the Brazilian Ministry of Health dated November 27, 2008 (Decree no. 2867) regarding the funds received by the Centers of Psychosocial Care (CAPS). In short, with regard to the new CAPS, the funds stopped to be paid according to actual productivity (proportional to the number of cases that receive care at different levels of severity), and the amount paid is established according to the calculation based on a history log consisting of the retrospective amounts sent to the previously implemented CAPS. The amounts account for around 70% (fixed) of the maximum value previously established. Those CAPS that had already been implemented were asked to improve the record of cases with the purpose of improving their history log. Thus, the new system does not reward additional efforts to broaden up the coverage provided to those who are most in need (intensive care), and rewards those CAPS that reduce their rhythm of care (and lower to the minimum rate or increase the proportion of cases of non-intensive care, which lead them to grow away from the guidelines of the CAPS of replacing/postponing/shortening psychiatric hospitalizations by providing intensive care within the family and community contexts).

The CAPS, which are regulated since February 2002 by the Administrative Rule no. 336 of the Ministry of Health, are aimed at providing care to patients with major mental disorders based on the rules of territoriality, integration, and social reintegration. Within its scope, the remuneration system that has been created prioritizes productivity and the quality of the service provided, resulting in the payment of higher amounts to the care of patients who present with worse disorganization and who need more intensive care. With the purpose of keeping these patients living with their families and integrated in their community, instead of taking them away from family and community gathering due to psychiatric hospitalization, the CAPS could adopt three care regimens, namely: intensive, semi-intensive, and non-intensive care. The most severe cases could be directly referred to the center to receive care, medication, guidance, etc, being provided with intensive care. As these patients would get better, they could be transferred to the semi-intensive regimen and, later, to the non-intensive care (up to three visits per month); similarly to what used to be offered by the former system of outpatient clinic of the Ministry of Health. The system was supposed to provide payments proportional to the efforts involved in each type of case, with lower amounts for the non-intensive procedure, and higher amounts for the intensive procedure. The funds would be sent by means of reimbursement, upon authorization of a high complexity procedure (APAC), which, as it may be assumed based on its name, resulted in a different amount according to the complexity of the procedure, requiring previous medical auditing so that the payment could be done.

The previous system was characterized by a self-regulated structure. For instance, at a CAPS II, the patients classified to receive intensive care could generate a maximum monthly amount of R$ 20,362.50, the semi-intensive patients, would generate R$ 14,310.00, and the non-intensive patients would generate R$ 4,155.00 (an amount calculated based on the number of days allowed for attendance multiplied by the value of the procedure, multiplied by the amount paid to the patients according to classification). The group of patients classified as intensive could generate in APAC a total amount of 45 units per month, the semi-intensive patients would generate 75 units,and the non-intensive would generate 110 units. Therefore, a CAPS II with a maximum productivity and receiving the maximum number of cases of high complexity and severity (and, as a consequence, with the highest potential to reduce the use of psychiatric beds) would generate the final monthly amount of R$ 39,127.50. Since November 27th 2008, based on historical averages of CAPS production, the monthly amount of R$ 31,866.00 was established, regardless of the complexity and frequency of care. The APAC has been used since then only as a means to prove that care was delivered. Other amounts were also similarly established for the other CAPS according to the historical average and based on its complexity. This caused a dramatic reduction in the need of control and relieved the local managers from the pressure for a higher productivity aiming at a higher remuneration, which automatically would lead to a higher complexity of the system and, as a consequence, a higher complexity of the management.

The comparative analysis of both systems allows us to state that the new measure, by simplifying the operation of the CAPS and reducing the need of control, discarded an accurate and modern parameter for the assessment of services based on productivity, which offered rewards based on the achievement of goals of maximum involvement of complex cases that usually would need hospitalization (the highest the amount charged by the CAPS, the closer it would be of the profile needed for the community regarding the care of more severe cases). The new system, on the other hand, by rewarding at a low level, may stimulate the progressive transformation of the CAPS into traditional outpatient clinics using a "modern" package, which are attended by patients for conventional visits every two weeks, and from which the more severe patient ends up being excluded or facing more difficulties of access. Thus, the necessary modernization of the public service disconnected from the remuneration related to productivity may result in a retrogression to the former conventional system of a dichotomy between outpatient clinic and psychiatric bed. We believe it is important to broaden the focus of the debate regarding this change and to try to go back to the former system, establishing again payments proportional to performance, productivity, achievement of the goals that guided the creation of the CAPS so that CAPS can become an actual alternative for the traditional model of mental health care.

REFERENCE

1. Gastal FL, Leite SO, Fernandes FN, de Borba AT, Kitamura CM, Binz MA, et al. Reforma psiquiátrica no Rio Grande do Sul: uma análise histórica, econômica e do impacto da legislação de 1992. Rev Psiquiatr RS. 2007;29(1):119-29.

There are no conflicts of interest associated with the publication of this letter.

Publication Dates

• Publication in this collection
  11 Mar 2010
• Date of issue
  2009