The establishment of a hospital medicine program in Brazil and the attempt to develop the specialty nationwide is both fascinating and challenging. Brazil has about 7,155 hospitals, with 443,210 beds available (including 2,727 public hospitals with 148,966 beds and 4,428 private facilities with 294,244 beds). 1 (See Table 1, p. 44.)
Historical problems in the public health system—also found in private sectors—have motivated physicians to address and improve inefficient management, insufficient financial support, the high number of frequent unnecessary admissions and re-admissions, extended length of stays, limited access to beds and medical services of high complexity, and overcrowded emergency departments.
SUS—Principles and Problems
The Brazilian public health system, called Sistema Único de Saúde, or SUS, is based on universal care and health as a right of citizenship and a state responsibility. Its main principles are universality, integrality, equity, decentralization, and social control.2 Less than half of the Brazilian population uses the SUS system exclusively. They use private health systems as a complement. This situation reflects the difficulties in the Brazilian public health system. The reasons for this duplicity highlight the challenges of our situation.
At the same time, physicians face serious problems. Most are employed by both the public and private sectors. Average salaries in the public system (by far the largest employer) are extremely low. Medical doctors are forced to work many extra hours, including numerous night shifts, creating a major barrier to the growth of physicians dedicated to horizontal inpatient care.
The government, in an attempt to improve medical—and hospital—assistance in the country with “a new kind of health assistance focused on high quality and efficient services,” has created the following projects: Humaniza SUS and QualiSUS.3,4 Theoretical support, operational contours, extent, and applicability are still not clear, however. For many medical doctors, these are merely abstract ideas. QualiSUS has renovated emergency departments in Brazil, but service quality has not improved enough. In our opinion, there are no public policies capable of providing good hospital services and efficient management in Brazilian hospitals, and—even if they existed—we would need to stop corruption in order to meet public commitments.
In Rio Grande do Sul, the Brazilian state where we work as medical doctors, the inadequate SUS reimbursement points to a calamitous future. Here, most hospital care is provided by philanthropic hospitals, which are more vulnerable in financial terms.5 (See Table 2, p. 44.) Despite being in a pioneer state in terms of hospital administration schools, with more than 2,000 graduates in recent years, these philanthropic hospitals have an estimated reimbursement deficit of more than 80%, an unattainable amount even for the best administrator.
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Staff from Nossa Senhora da Conceição Hospital
Could Hospitalists Be Part of a Solution?
On top of these growing deficits, we have witnessed the closing of more than 2,000 available beds in the last four years, as well as the loss of 10,000 hospital positions and the complete closing of eight hospitals. Aiming to ensure the survival of this hospital system, physicians, health professionals, and organizations involved with hospitals have joined forces to find a solution. Their logo is best translated as “More Health for the Hospitals,” and our group supports their goals.6
Looking at the situation from a different perspective, we see many opportunities for Brazilian hospitalists. Their potential contribution to the quality and safety of medical care is an obvious advantage for hospital management and patients. We predict that this scenario can be accomplished—even in our state. It is possible to make a profit in public as well as in lucrative private institutions. In public institutions, a profit can be made as long as hospital administrators use adequate policy. We believe that in private institutions, though not in philanthropic ones, the key point is hospital administration cooperation and goodwill. Elucidation of hospitalists’ capabilities will open the necessary doors. We are ready to reduce the hospitalization fee and length of stay—among other costs. In this way, we can work with the administrator to develop tools for systems and quality improvements.