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After heated debate, U.S. Senators voted Thursday the historic reform of health coverage in the United States. They must now agree on a final text with the House of Representatives.

The senators of the United States voted to reform health insurance. A compromise between Democrats and heated debates with the Republicans, The text aims to provide health insurance to 31 of the 36 million Americans who do not. The senators approved the text by 60 votes against 39, or without any voice of Republican opposition.

The bill is historic since President Theodore Roosevelt (1901-1909), several generations of politicians have tried unsuccessfully to reform the health system of the United States.

“Very enthusiastic”

In an interview with The Washington Post Tuesday, December 22, Barack Obama said “not supporting the bill (only) the lip. I am very enthusiastic about what we have achieved.” He assured that the essence of the reform has not been altered; the Senate has made “95%” of what he had promised.

“Are these pieces of legislation containing exactly what I want? Of course not. But they include the necessary measures to reduce costs (of health) for businesses, families and the state,” he pleaded.

The text of the Senate, unlike the previously voted in the House of Representatives last November 7, does not create an insurance fund run by the state in competition with private insurers. Barack Obama has acknowledged that the famous “public option” had “become a source of contention between the left and right.”

Democratic Majority

The right wing of the Democratic Party has long battled and finally got satisfaction to exclude the device from the final bill.

An initial vote to close the debate has already occurred on the night of 20 to 21 December last. The Democratic majority has proved on this occasion she was receiving 60 votes now out of 100 for the adoption of the draft. It may thus prevent an obstruction of the Republicans in approving the text: neither of them has also voted to close the debate.

U.S. opposition to any attempt to block the reform that they believe it will worsen the deficit and will raise the price of insurance policies.

Republican Opposition

The Republican leader Mitch McConnell said Tuesday, December 22 that the “final vote in the Senate is not the final vote. The discussions will continue in effect in January between the House of Representatives and Senators to merge the two versions of the text.

In this final stage of the bill, the Democratic leader, Harry Reid, told the press: “We are focused on the adoption of this bill in the Senate. We’ll take care of things to come later.

And discussions between the two chambers should be strained, including the public option or the issue of using government funds for abortion.

International Forum SECTOR REFORM HEALTH

Developing information systems, as the minimum basic set of hospital discharge data, which know the product enable the attention of health systems is an indispensable basis. At the same time is required development of accounting systems that will allow an approach to efficiency. Currently available tools, even with its limitations are useful for systematizing medical practice, measurement of the results of care processes and to share the risk of decisions between managers and clinicians. We identified three areas of clinical management:

The determination of effective clinical practices, developed based on based medicine evidence and used as instruments development of clinical protocols. Process management, which rearranges the attention focused on the internal customers (staff) and external and the continuum of care. The organization and management services that facilitate definition of responsibility centers are involving to clinical management of their services through the clinical budgeting. Since the beginning of the process which must lead to autonomous management of an establishment health is introduces training of managers and professionals principles and techniques of clinical management and whether furthermore, the organization is plotted targets for improvements in clinical practice and customer service, the possibilities success and consolidation of reform will increase considerably.

Recommendations for improved management should combined measures to improve system management the establishments and the process of care that are consistent and mutually reinforcing. Management measures should be accompanied by the appropriate changes in regulation of the system, deregulating of strengthening operational and monitoring results.

In a well developed regulatory framework, the actions of a pilot or experiences limited in the macro and micro are most useful for universal measures because latter block initiatives the suppliers, new experiences and adapting to environment. It is not possible to accurately predict the success of a management innovation, and consequently will be needed experiences and go out rectified in accordance with results will be obtained. This requires a high capacity for evaluation and a culture of transparency and communication of the results only possible in an environment of consensus and negotiation.

Conclusions

System Reforms health develop in a given environment that conditions and, generally, as part of the reform. This is a first-order condition must be known and analyzed by those who prepare proposals and decision makers. Reforms often focus exclusively the care services to individuals and, therefore, only can produce results that can be achieved with changes in themselves. The integration of public financing is a policy that promotes equity and efficiency. If the integration into a single fund to provide universal coverage is not feasible, should be sought integration formulas that get double coverage and avoid cross-subsidization between public funds or between public funds and private. Charged directly for services should be regulated and must be applied cautiously because of its implications on equity and the difficulty of their control. Reform policies should include determination of benefits that the State guarantees the population and how to access them. The processes decentralization may be useful to bring services to the population, share risks and democratize decision whether they are carried out through an orderly process of distribution functions, taking into account ability of management receiving powers and protecting equity and integrated care for people.

Measures strengthening management capacity must reach everyone levels system, from the regulator to the care professionals and must be consistent with objectives system and serve to promote them.
The management establishments and clinical management will develop best in a decentralized, respecting and supporting initiatives the providers as well as professional groups, and evaluating experiments carried out. Gradual negotiation and consensus must be present in everyone times of reform.

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Actions on the management of the establishments – middle management

The autonomy of the service providers together with the strengthening of its capacity management will together with the changes in forms of professional work, the way reform is operational.
The autonomy and management capacity can be increased in many different ways and at present can not speak of an optimal model for facilities management health, as there is the model optimal care. Any legal formula can be useful depending on the environment in which to develop and all organizational alternatives may be valid. The partnerships between various public bodies or private transfer of the management public assets to private entities, the delegation of powers to Public institutions can serve as examples, but each country can find appropriate formulas to apply health which probably already being used in other sectors.

Organizational needs of the services rapidly changing function of the changes in the demographic and epidemiological population profile, medical technology and communication and conceptual changes in the forms of care. The practical effect is, however, much slower because it is conditioned by infrastructure existing the knowledge and skills the human resource and capacity constraints investment the countries.

Understanding the needs of the people, separation of duties, management autonomy and the availability of different mechanisms of purchase of services that have been described in the macro should be used to carry out diverse experiences in the service organization to allow adaptation to different environments.

Management actions on the care process: micro

It’s called micro – the set of tools and techniques to analyze clinical practice from perspective of efficiency. It is probably the least known area of management and applied in Latin America. The most relevant decisions health systems are taken the health professionals, especially the physicians, direct care users and services at this level makes most of health spending. Investigations into variability in clinical practice show that doctors make decisions based, in large part, scientifically unproven belief that using inadequate resources for this cause can be very important. This is due mainly the high level of uncertainty surrounding medical decisions: on the diagnosis and information provided by the further examination of the efficacy and effectiveness of treatments and their timing. Clinical management tries to reduce inefficiencies due to these causes and involve medical management resources.

Shares of improving the management of the health systems can be classified into three levels: actions about the bodies of the system, grouped under the name macro; actions on facilities providing health services or middle management and actions on the process of health care or micromanagement. The improved system performance will be achieved with the combination of three levels auctions. The management changes should be strongly targeted major objectives of health systems (population coverage, improving equity, increasing allocative efficiency, containment of spending growth health), So that they are real instruments for achieving themselves.

Changes in management of system without clearly defined objectives will lead you in the direction of groups with higher wishing pressure capability, regardless of what these changes are.

Actions on system management: macro

The health systems of Latin America need to increase coherence between supply and services needs of the population (overlapping partially with the demand expressed). Therefore, the planning based on these needs to be reinforced. The definition of priorities, performance guaranteed baskets of services or any other form of marking the supply of system must be following the study of population needs and developing health plans.
The ability to regulation the system must adapt to induced reforms changes. The regulation is quite simple in the integrating systems from providing financing to services in a single organism, but its complexity increases rapidly with separation measures functions and decentralization. The relationship between changes and regulatory capacity and as increased costs and management information that it produces, it must be carefully valued.

The implementation of allocation mechanisms financial resources consistent with the goals organization is probably the most powerful incentive is the lead financier for the production of the health establishments. In order to allocation mechanisms work properly it is necessary that the allocator and the service provider is independent and therefore there is an organic separation or functional procurement functions and service provision. This separation has an additional two positive effect: buyer and supplier organizations have different objectives, competitive among themselves, which encourage efficiency in both. The buyer wants to maximize the delivery of services to the insured resources available, while supplier will produce services they have purchased with minimum consumption of inputs. This is a cultural change of great importance within the systems coming from a model of vertical integration of functions.

Although it is rare, ovarian cancer tends to recur and to be very difficult to handle. Faced with this evil woman, therapeutic vaccination is a groundbreaking approach brings high hopes.
Is ovarian cancer relapse formidable vaccine contra les recidivist ovaries cancer?

The ovarian cancer is rare: there are about 4 500 new cases diagnosed each year in France, but in the same 3500 women die. The mortality rates approaching 75% in fact the most serious of gynecological cancers. He represents the 5th cause of cancer death in women. The average age of onset is 60 years with a peak incidence between 75 and 79 years, but it can reach younger women or girls.

5 to 10% of cases are genetic in origin, found in families with a gene predisposing Mutated BRCA1 or BRCA2. Despite effective treatment, a screening often delayed due to the discretion of symptoms, largely explains the very poor prognosis of this cancer. The treatment is both surgeries, in order to completely remove the tumor, chemotherapy, associating carboplatin and paclitaxel infusion of 6 courses.

Despite the excellent results of this first line therapy, the problem remains high recurrence rate. Women who suffer from cancer at late stage are put into complete remission in 80% of cases but 75% of them relapse after an average 16 to 18 months. “Treatment of relapse has progressed,” says Professor Pujade-Lauraine, chief of medical oncology at the Hotel-Dieu. “However, the median survival does not exceed 3 to 4 years, which is particularly disappointing, especially compared with the percentage of patients in remission initially” he added. “The challenge today is to develop a treatment subsequent to first-line treatment, may prevent relapse” said Professor Jacques Dauplat, chief of surgical oncology center Jean Perrin1.
An original therapeutic approach: immunotherapy

All tests for years with conventional treatments are improving the rate of relapse, ended in failure. A totally new approach to treatment is a therapeutic vaccine that would prevent recurrence after initial successful treatment. The principle of this approach immunotherapeutic based on injection of a molecule called Abagovomab patients suffering from ovarian cancer. The vaccine stimulates the immune system of women so that it selects and destroys tumor cells to prevent tumor recurrence. Focus on principle rather conventional Vaccine:

* This molecule is an antigen designed to resemble the CA125 antigen, a protein found in large quantities on the surface of tumor cells in ovarian cancer. The Abagovomab is nevertheless sufficiently different from the CA125 in order to induce, once injected, the immune response of the patient against him, and thereby against the CA125 antigen, very close.

* A classic immune response occurs when: the antibodies induced by the patient specifically recognize antigens CA125 in the tumor cells and bind to leading, ideally elimination of tumor cells carrying the antigen, now recognized as foreign. If the system works in practice is therefore the patient herself who synthesizes antibodies eradicating the tumor. Thanks to the vaccine based Abagovomab, the immune system should be able to recognize and attack tumor cells that have the protein CA125.

This could bring hope that the immune system starts to fight all residual tumor cells and that they succeed and to prevent any recurrence of the disease. “The medical community has great hopes on the immunotherapy. She hopes treatment that will prevent recurrence often fatal cancer of the ovary, “said Professor Pujade-Lauraine.
Ovarian cancer: an international study on a vaccine

Driving in 9 countries, the clinical MIMOSA2 testing the effectiveness of the vaccine based Abagovomab.

Launched in 2006 by Menarini pharmaceutical group, this trial represents the first phase III study of this size, to test the Abagovomab in consolidation therapy in women with ovarian cancer and who responded completely the first-line chemotherapy. The goal is to answer this question; does this vaccine capable of preventing the recurrence of high risk patients? Beyond this, the criteria are also studied overall survival, safety, treatment and duration of the immune response. France has since the end of 2008 among the countries involved.

The first results are expected in early 2011 and the final conclusions will be known in 2015. If Abagovomab meets these expectations, patients may fully benefit from the advanced first-line treatment in this disease and see their hopes of survival increased significantly in years to come.